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Barreira CESR, Miranda AP, Peixoto TF, Pinheiro RN. Intraoperative indocyanine green angiography in preventing hypoparathyroidism after thyroid cancer surgery. J Surg Oncol 2024. [PMID: 38963907 DOI: 10.1002/jso.27762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/18/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The aim of this study was to determine whether the use of indocyanine green angiography to identify devascularized parathyroids during thyroidectomy for thyroid cancer would decrease the rates of postoperative hypoparathyroidism. METHODS Retrospective study of patients who had undergone total thyroidectomy for treatment of thyroid cancer between March 2021 and March 2023. The indocyanine group included patients with all four parathyroids identified and evaluated by indocyanine green angiography at the end of the procedure. Those with parathyroid glands classified with no vascularization had the glands autotransplanted. A group without indocyanine angiography was used to compare results. RESULTS The analysis included 100 patients in each group. Indocyanine angiography identified 14.75% of devascularized parathyroids at surgery. The number of parathyroids with a score of 2 (i.e., good vascularization) was not a safe predictor of normal parathyroid hormone levels after surgery. Indeed, 29.2% of the patients with three parathyroids with a score of 2 developed transient hypoparathyroidism. Permanent hypoparathyroidism occurred in 7% of the patients without indocyanine group and in none of the patients in the indocyanine group (p = 0.014). CONCLUSION Intraoperative angiography with indocyanine green could contribute to reduce the occurrence of permanent hypoparathyroidism in patients undergoing surgical treatment for thyroid cancer.
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Affiliation(s)
- Carlos Eduardo Santa Ritta Barreira
- Head and Neck Surgery, Hospital DASA BRASÍLIA, Brasília, Federal District, Brazil
- Head and Neck Surgery, Hospital DF STAR, Brasília, Federal District, Brazil
- Head and Neck Surgery, Hospital SÍRIO-LIBANÊS, Brasília, Federal District, Brazil
| | - André Póvoa Miranda
- Head and Neck Surgery, Hospital DF STAR, Brasília, Federal District, Brazil
- Head and Neck Surgery, Hospital Santa Luzia, Brasília, Federal District, Brazil
| | - Thaísa Fabiana Peixoto
- General Surgery, Hospital DASA BRASÍLIA, Brasília, Federal District, Brazil
- General Surgery, Hospital DAHER, Brasília, Federal District, Brazil
| | - Rodrigo Nascimento Pinheiro
- Oncological Surgery, Hospital DF STAR, Brasília, Federal District, Brazil
- Oncological Surgery, Hospital Santa Luzia, Brasília, Federal District, Brazil
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Del Rio P, Boniardi M, De Pasquale L, Docimo G, Iacobone M, Materazzi G, Medas F, Minuto M, Mullineris B, Polistena A, Raffaelli M, Calò PG. Management of surgical diseases of Primary Hyperparathyroidism: indications of the United Italian Society of Endocrine Surgery (SIUEC). Updates Surg 2024; 76:743-755. [PMID: 38622315 PMCID: PMC11130045 DOI: 10.1007/s13304-024-01796-5] [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: 12/19/2023] [Accepted: 02/25/2024] [Indexed: 04/17/2024]
Abstract
A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in parathyroid surgery published in 2014, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 12 members of the SIUEC highly trained and experienced in thyroid and parathyroid surgery. The main topics concern diagnostic test and localization studies, mode of admission and waiting time, therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications), hospital discharge and patient information, outpatient care and follow-up, outpatient initial management of patients with pHPT.
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Affiliation(s)
- Paolo Del Rio
- Unit of General Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Boniardi
- Endocrine Surgery Unit, Department of General Oncology and Mini-Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Loredana De Pasquale
- Thyroid and Parathyroid Unit, Otolaryngology Unit, Department of Health Sciences, ASST Santi Paolo E Carlo, Università Degli Studi Di Milano, Milan, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Docimo
- Division of Thyroid Surgery, University of Campania "L. Vanvitelli", Naples, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padua, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Materazzi
- Endocrine Surgery Unit, University Hospital of Pisa, Pisa, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Minuto
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Barbara Mullineris
- Unit of General Surgery, Emergency and New Technologies, Modena Hospital, 41126, Modena, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Polistena
- Department of Surgery, University of Rome Sapienza, Policlinico Umberto I, Rome, Italy.
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Marco Raffaelli
- Centro Dipartimentale Di Chirurgia Endocrina E Dell'Obesità, U.O.C. Chirurgia Endocrina E Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
- Centro Di Ricerca in Chirurgia Delle Ghiandole Endocrine E Dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
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Polkin VV, Isaev PA, Severskaya NV, Ivanov SA, Kaprin AD. [Indocyanine green angiography in assessment of parathyroid remnant perfusion after subtotal parathyroidectomy: a case report]. Khirurgiia (Mosk) 2024:61-66. [PMID: 38380466 DOI: 10.17116/hirurgia202402261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
A 72-year-old female patient with chronic kidney disease stage presented with multiple parathyroid adenomas and tertiary hyperparathyroidism. SPECT/CT with 99mTc-MIBI revealed accumulation of radiopharmaceuticals in 2 out of 4 parathyroid glands. Ultrasound established localization of all parathyroid glands. Subtotal parathyroidectomy with excision of 3 glands and resection of half of the fourth gland was performed. Intraoperative indocyanine green angiography was performed to identify all parathyroid glands and remnant perfusion. There was normal parathyroid function after 6 months.
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Affiliation(s)
- V V Polkin
- Tsyb Medical Research Radiology Center, Obninsk, Russia
| | - P A Isaev
- Tsyb Medical Research Radiology Center, Obninsk, Russia
| | | | - S A Ivanov
- Tsyb Medical Research Radiology Center, Obninsk, Russia
- People's Friendship University of Russia, Moscow, Russia
| | - A D Kaprin
- National Medical Research Radiology Centre, Obninsk, Russia
- People's Friendship University of Russia, Moscow, Russia
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Vabalayte K, Romanchishen A, Somova A. Intraoperative prevention of postoperative hypoparathyroidism. Front Endocrinol (Lausanne) 2023; 14:1206881. [PMID: 38027177 PMCID: PMC10663325 DOI: 10.3389/fendo.2023.1206881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Objective More than 30,000 thyroid surgeries are performed annually in the Russian Federation. The surgeries are relatively safe because of the prevention methods for postoperative complications. Currently, there is no single effective method of postoperative hypoparathyroidism prevention. This complication is frequently reported and may be health and life-threatening. Aim We aimed to estimate the effectiveness of the intraoperative ICG-angiography and intrathyroid injection of Brilliant Green for the prevention of postoperative hypoparathyroidism. Material and methods One hundred and forty-three thyroidectomies were performed. Patients were divided into three groups: intraoperative angiography was used in 24 cases; Brilliant Green was injected in 58 cases to identify parathyroid glands; the visual estimation of the parathyroid preservation was used in 61 cases. Calcium level was measured in all patients before and after surgery. Results Calcium level in the serum before and after surgery was 2.37±0.14 and 2.27±0.17 in Group 1, 2.38±0.16 and 2.21±0.16 in Group 2, and 2.39±0.17 and 2.18±0.19 in Group 3. Postoperative hypocalcemia was more prominent in the group with the visually estimated PTG than in the two other groups. The differences in postoperative calcium levels in Groups 1 and 3 were statistically different. Pre- and postoperative Parathormone levels were 6.2±0.4 in Group 1, 5.6±0.57 in Group 2, and 3.5±0.32 in Group 3. Postoperative levels significantly differed in Groups 1 and 3 (p<0.01) and in Groups 2 and 3 (p<0.05). Conclusions ICG-angiography and intrathyroid injection of the Brilliant Green are safe methods of identification and sparing of the parathyroid glands. The severity of hypocalcemia and hypoparathormonemia in Group 3 shows the necessity of finding new methods in endocrine surgery to improve patient outcomes.
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Affiliation(s)
| | | | - Aleksandra Somova
- Federal State Budgetary Educational Institution of Higher Education “Saint-Petersburg State University”, St. Petersburg, Russia
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Sępek M, Marciniak D, Głód M, Kaliszewski K, Rudnicki J, Wojtczak B. Risk Factors for Calcium-Phosphate Disorders after Thyroid Surgery. Biomedicines 2023; 11:2299. [PMID: 37626794 PMCID: PMC10452658 DOI: 10.3390/biomedicines11082299] [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: 06/23/2023] [Revised: 08/04/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION Iatrogenic hypoparathyroidism following thyroidectomy is one of the most common complications significantly reducing patients' quality of life. OBJECTIVES This study aimed to analyze the risk factors for calcium-phosphate disorders following thyroidectomy. PATIENTS AND METHODS The study group consisted of 211 patients who underwent thyroidectomy for different conditions in 2018-2020. Demographic, clinical and surgical risk factors were analyzed against hypoparathyroidism and hypocalcemia. RESULTS Hypoparathyroidism occurred in 15.63% of patients, and hypocalcemia occurred in 45% of those operated on. There was statistical significance between hypoparathyroidism and the extent of thyroid surgery: thyroidectomy vs. lobectomy (p = 0.02, OR = 4.5) and surgeon experience (p = 0.016, OR = 6.9). Low preoperative PTH levels were associated with a higher incidence of hypoparathyroidism (p = 0.055, OR = 0.9). There was a statistically significant correlation between the occurrence of hypocalcemia and preoperative vitamin D deficiency (p = 0.04, OR = 3.5). Low calcium levels before surgery were associated with a higher incidence of hypocalcemia (p = 0.051, OR = 0.5). Meta-analyses of selected risk factors confirmed that the most significant factor in the incidence of hypocalcemia was a decrease in PTH levels (p < 0.001). CONCLUSIONS The extent of thyroid surgery and the experience of the surgeon are the most significant risk factors for hypoparathyroidism. Hypocalcemia is much more common than hypoparathyroidism. Among the risk factors for hypocalcemia, in addition to the decrease in parathormone levels due to iatrogenic parathyroid damage, we should mention vitamin D deficiency in the preoperative period.
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Affiliation(s)
- Monika Sępek
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.S.); (K.K.); (J.R.)
| | - Dominik Marciniak
- Department of Dosage Form Technology, Wroclaw Medical University, Borowska Street 211 A, 50-556 Wroclaw, Poland;
| | | | - Krzysztof Kaliszewski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.S.); (K.K.); (J.R.)
| | - Jerzy Rudnicki
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.S.); (K.K.); (J.R.)
| | - Beata Wojtczak
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland; (M.S.); (K.K.); (J.R.)
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Park SY, Choi YS, Hwang YM, Yi JW. Robot-Assisted Parathyroidectomy Using Indocyanine Green (ICG) Fluorescence in Primary Hyperparathyroidism. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1456. [PMID: 37629746 PMCID: PMC10456807 DOI: 10.3390/medicina59081456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Surgical treatment for primary hyperparathyroidism (PHPT) has evolved from bilateral exploration through a long transcervical incision to focused parathyroidectomy with a minimal incision above the pathologic gland. Recently, endoscopic or robot-assisted parathyroid surgery without direct neck incision has been introduced. The aim of this study was to investigate the effectiveness of indocyanine green (ICG) fluorescence as a new method for the visual identification of abnormal hyperfunctioning parathyroid glands in robot-assisted parathyroidectomy using FireflyTM technology. We also aimed to conduct a comparative analysis between robot-assisted parathyroidectomy and conventional focused parathyroidectomy in order to identify clinical differences between the two surgical approaches. Materials and Methods: A total of 37 patients with PHPT underwent parathyroidectomy at a single university hospital between September 2018 and December 2022. Thirty-one patients underwent open focused parathyroidectomy (open group), and six patients underwent robot-assisted parathyroidectomy (robot group). Pre-operative localization via parathyroid SPECT-CT and an intraoperative parathyroid hormone (IOPTH) assay were used to successfully remove the pathologic parathyroid in both groups. ICG was administered only in the robot group. Results: Pathologic parathyroid showed a persistent fluorescence pattern under near-infrared vision. After the removal of the fluorescent parathyroid gland, IOPTH was normalized in all six patients in the robot group. However, the open group showed shorter hospital stays (1.8 ± 1.2 vs. 3.0 ± 0.0 days, p < 0.001) and shorter operation times (91.1 ± 69.1 vs. 152.5 ± 23.6 min, p = 0.001) than the robot group. After 6 months of surgery, PTH, calcium, and ionized calcium levels were all normalized without significant differences between the groups. Conclusions: Robot-assisted parathyroidectomy using ICG is helpful for the visual identification of the pathologic parathyroid gland. The advantage of robot parathyroidectomy is a better cosmetic outcome. However, it still does not show better clinical outcomes than conventional open focused parathyroidectomy.
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Affiliation(s)
| | | | | | - Jin Wook Yi
- Department of Surgery, Inha University Hospital & College of Medicine, Incheon 22332, Republic of Korea
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Rupp GE, Barba P, Goldhaber NH, Hu J, Bouvet M. Indocyanine green fluorescence guided resection of parathyroid adenoma of the carotid sheath: a case report and review of the literature. Gland Surg 2023; 12:548-554. [PMID: 37200930 PMCID: PMC10186167 DOI: 10.21037/gs-22-589] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/09/2023] [Indexed: 08/07/2024]
Abstract
BACKGROUND Ectopic parathyroid tissue can pose difficulties in diagnosis, management, and resection of adenomas in patients with hyperparathyroidism. The use of multimodal pre-operative imaging is recommended due to the diverse anatomic presentation of parathyroid adenomas and the potential presence of multiple adenomas. Resection failure still can occur, however, indocyanine green (ICG) fluorescence imaging is an intraoperative tool that has potential to help address this challenge. In the case which follows we demonstrate the use of ICG fluorescence imaging to assist in successful resection of a parathyroid adenoma located within the carotid sheath. CASE DESCRIPTION We present the case of a 75-year-old woman with primary hyperparathyroidism due to a parathyroid adenoma localized to the left carotid sheath, posterior to the carotid artery. Careful resection was aided by ICG fluorescence guidance allowing for complete resection and immediate postoperative restoration of normal parathyroid hormone and calcium levels. The patient had no peri-operative complications and had an unremarkable post-operative course. CONCLUSIONS The anatomical heterogeneity of parathyroid gland adenomas within and around the carotid sheath presents a unique diagnostic and surgical scenario; however, the use of intra-operative ICG, as presented in this case, has important implications for endocrine surgeons and surgical trainees alike. This tool provides improved intra-operative identification of the parathyroid tissue allowing for safe resection, especially in cases involving critical anatomical structures.
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Affiliation(s)
- Garrett E. Rupp
- School of Medicine, University of California, San Diego, CA, USA
| | - Patrick Barba
- School of Medicine, University of California, San Diego, CA, USA
| | | | - Jingjing Hu
- Department of Pathology, University of California, San Diego, CA, USA
| | - Michael Bouvet
- Department of Surgery, University of California, San Diego, CA, USA
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Bang YJ, Choi HJ, Kim I, Lee MH, Lee S, Shin HJ, Nam SJ, Lee JE, Chae BJ, Lee SK, Ryu JM, Kim SW. The efficacy and safety of an indocyanine green-hyaluronic acid mixture (LuminoMark™) for localization in patients with non-palpable breast lesions: A multicenter, randomized, open-label, parallel phase 3 clinical trial. Front Oncol 2023; 13:1039670. [PMID: 37035212 PMCID: PMC10080039 DOI: 10.3389/fonc.2023.1039670] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Purpose The incidence of early tumor detection is increasing due to popularization of breast cancer screening and the development of imaging techniques. Thus, suitable preoperative localization is required for proper diagnosis and treatment of non-palpable breast lesions. The purpose of this study was to evaluate the efficacy and safety of indocyanine green (ICG)-hyaluronic acid (HA) mixture for lesion localization compared to activated charcoal. Methods This was a multicenter, randomized, open-label, parallel phase 3 clinical trial performed at four centers in Korea. Female patients scheduled for surgery to remove non-palpable breast lesions were enrolled. One hundred and nine patients were randomly assigned to a control group (activated charcoal: 0.3. - 1 mL) or a study group (ICG-HA mixture, 0.2 mL) for the localization of a breast lesion. The primary endpoint was the accuracy of resection. Secondary endpoints included the technical success rate, histopathological accuracy, skin pigmentation rate, and adverse event rate. Results A total of 104 patients were eligible for per-protocol analysis (control group, n = 51; study group, n = 53). The accuracy of resection in the study group was not inferior to that of the control group (90.57% vs. 98.04%, 95% confidence interval (CI): -2.31 - 18.91, p = 0.21). There was no statistically significant difference in technical success rate between the two groups (marking on breast skin: p = 0.11, marking on the excised specimen: p = 0.12). However, there were statistically significant differences in histopathological accuracy (0.26 ± 0.13 vs. 0.33 ± 0.17, p = 0.01) and skin pigmentation rate (0.00% vs. 30.77%, p< 0.01). Adverse events were not reported in either group. Conclusions When localization was performed using ICG-HA, the accuracy of resection was not inferior to that of activated charcoal. However, skin pigmentation rate was significantly lower. In conclusion, ICG-HA is effective and safe for localizing of non-palpable breast lesions.
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Affiliation(s)
- Yoon Ju Bang
- Department of Surgery, Samsung Changwon Hospital, School of Medicine, Sungkyunkwan University, Changwon, Republic of Korea
| | - Hee Jun Choi
- Department of Surgery, Samsung Changwon Hospital, School of Medicine, Sungkyunkwan University, Changwon, Republic of Korea
| | - Isaac Kim
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Moo-Hyun Lee
- Department of Surgery, School of Medicine, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea
| | - Seeyoun Lee
- Center for Breast Cancer, National Cancer Center Hospital, Goyang, Republic of Korea
| | - Hyuk Jai Shin
- Department of Surgery, Myongji Hospital, College of Medicine, Hanyang University, Goyang, Republic of Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jeong Eon Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Byung-Joo Chae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Se Kyung Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
- *Correspondence: Seok Won Kim,
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Somova SD, Vabalayte KV, Romanchishen AF. Safe thyroid surgery: comparison effectiveness of ICG angiography and intrathyroidal brilliant green injection for the prevention of postoperative hypoparathyroidism. ENDOCRINE SURGERY 2022. [DOI: 10.14341/serg12757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND: More than 30,000 surgical interventions on the thyroid gland are performed annually in the Russian Federation. Surgeons are developing methods for the prevention of various postoperative complications, and therefore operations on this organ are considered relatively safe. Currently, there is no unequivocal effective method to prevent postoperative hypoparathyroidism. This complication is often recorded and can threaten the life and health of the patient, which is contrary to the concept of safe surgery.AIM: To evaluate the effectiveness of intraoperative ICG angiography and intrathyroidal injection of brilliant green for the prevention of postoperative hypoparathyroidism.MATERIALS AND METHODS: 143 thyroidectomies were performed. The patients were divided into 3 groups: intraoperative angiography was used in 24 cases, brilliant green was injected to identify the parathyroid glands in 58 cases, visual assessment of the preservation of the parathyroid glands was used in 61 case. Calcium levels were measured in all patients included in the study before and after surgery.RESULTS: Serum calcium levels in the pre- and postoperative period: 2.37±0.14 and 2.27±0.17 in group 1, and 2.38±0.16 and 2.21±0.16 in group 2, 2.39±0.17 and 2.18±0.19 in group 3. Hypocalcemia in the postoperative period was significantly higher in the group with a visual assessment of the parathyroid glands relative to the first two groups. Differences between calcium levels in the postoperative period in groups 2 and 3 were significant with a probability of more than 99% (p<0.01). Significant differences (≥95%) in calcium levels in the postoperative period between groups 1 and 2 (p < 0.05) were obtained. Serum PTH levels in the postoperative period: 6,2±0,4 in group 1, 5,6±0,57 in group 2, 3,5±0,32 in group 3. Differences between PTH levels in the postoperative period in groups 1 and 3 were significant with a probability of more than 99% (p<0.01). Significant differences (≥95%) in PTH levels in the postoperative period between groups 2 and 3 (p < 0.05) were obtained.CONCLUSION: ICG angiography and brilliant green intrathyroidal injection are safe methods for identifying and preserving the parathyroid glands. The high level of hypocalcemia in group 3 indicates the need to search for new techniques in endocrine surgery in order to improve the safety of patients undergoing surgical treatment of thyroid pathology.
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Affiliation(s)
- S. D. Somova
- Scientific and Practical Center for Inflammatory, Metabolic and Oncological Diseases of the Endocrine System Organs of the Institute of High Technologies, St. Petersburg State University
| | - K. V. Vabalayte
- Scientific and Practical Center for Inflammatory, Metabolic and Oncological Diseases of the Endocrine System Organs of the Institute of High Technologies, St. Petersburg State University
| | - A. F. Romanchishen
- Scientific and Practical Center for Inflammatory, Metabolic and Oncological Diseases of the Endocrine System Organs of the Institute of High Technologies, St. Petersburg State University
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Choi J, Shin JG, Tak YO, Seo Y, Eom J. Single Camera-Based Dual-Channel Near-Infrared Fluorescence Imaging system. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22249758. [PMID: 36560127 PMCID: PMC9786791 DOI: 10.3390/s22249758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/02/2022] [Accepted: 12/09/2022] [Indexed: 05/29/2023]
Abstract
In this study, we propose a single camera-based dual-channel near-infrared (NIR) fluorescence imaging system that produces color and dual-channel NIR fluorescence images in real time. To simultaneously acquire color and dual-channel NIR fluorescence images of two fluorescent agents, three cameras and additional optical parts are generally used. As a result, the volume of the image acquisition unit increases, interfering with movements during surgical procedures and increasing production costs. In the system herein proposed, instead of using three cameras, we set a single camera equipped with two image sensors that can simultaneously acquire color and single-channel NIR fluorescence images, thus reducing the volume of the image acquisition unit. The single-channel NIR fluorescence images were time-divided into two channels by synchronizing the camera and two excitation lasers, and the noise caused by the crosstalk effect between the two fluorescent agents was removed through image processing. To evaluate the performance of the system, experiments were conducted for the two fluorescent agents to measure the sensitivity, crosstalk effect, and signal-to-background ratio. The compactness of the resulting image acquisition unit alleviates the inconvenient movement obstruction of previous devices during clinical and animal surgery and reduces the complexity and costs of the manufacturing process, which may facilitate the dissemination of this type of system.
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Affiliation(s)
- Janghoon Choi
- Intelligent Photonic IoT Research Center, Korea Photonics Technology Institute, Gwangju 61007, Republic of Korea
- Department of Biomedical Science & Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
| | - Jun-Geun Shin
- Optical Precision Measurement Research Center, Korea Photonics Technology Institute, Gwangju 61007, Republic of Korea
| | - Yoon-Oh Tak
- Intelligent Photonic IoT Research Center, Korea Photonics Technology Institute, Gwangju 61007, Republic of Korea
| | | | - Jonghyun Eom
- Intelligent Photonic IoT Research Center, Korea Photonics Technology Institute, Gwangju 61007, Republic of Korea
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Choi J, Shin JG, Kwon HS, Tak YO, Park HJ, Ahn JC, Eom JB, Seo Y, Park JW, Choi Y, Eom J. Development of Intraoperative Near-Infrared Fluorescence Imaging System Using a Dual-CMOS Single Camera. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22155597. [PMID: 35898101 PMCID: PMC9370963 DOI: 10.3390/s22155597] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/17/2022] [Accepted: 07/22/2022] [Indexed: 06/01/2023]
Abstract
We developed a single-camera-based near-infrared (NIR) fluorescence imaging device using indocyanine green (ICG) NIR fluorescence contrast agents for image-induced surgery. In general, a fluorescent imaging system that simultaneously provides color and NIR images uses two cameras, which is disadvantageous because it increases the imaging head of the system. Recently, a single-camera-based NIR optical imaging device with quantum efficiency partially extended to the NIR region was developed to overcome this drawback. The system used RGB_NIR filters for camera sensors to provide color and NIR images simultaneously; however, the sensitivity and resolution of the infrared images are reduced by 1/4, and the exposure time and gain cannot be set individually when acquiring color and NIR images. Thus, to overcome these shortcomings, this study developed a compact fluorescent imaging system that uses a single camera with two complementary metal-oxide semiconductor (CMOS) image sensors. Sensitivity and signal-to-background ratio were measured according to the concentrations of ICG solution, exposure time, and camera gain to evaluate the performance of the imaging system. Consequently, the clinical applicability of the system was confirmed through the toxicity analysis of the light source and in vivo testing.
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Affiliation(s)
- Janghoon Choi
- Intelligent Photonic IoT Research Center, Korea Photonics Technology Institute, Gwangju 61007, Korea; (J.C.); (Y.-O.T.)
- Department of Biomedical Science & Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Korea;
| | - Jun Geun Shin
- Optical Precision Measurement Research Center, Korea Photonics Technology Institute, Gwangju 61007, Korea;
| | - Hyuk-Sang Kwon
- Department of Biomedical Science & Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Korea;
| | - Yoon-Oh Tak
- Intelligent Photonic IoT Research Center, Korea Photonics Technology Institute, Gwangju 61007, Korea; (J.C.); (Y.-O.T.)
| | - Hyeong Ju Park
- Medical Laser Research Center, Dankook University, Cheonan 31116, Korea; (H.J.P.); (J.-C.A.)
| | - Jin-Chul Ahn
- Medical Laser Research Center, Dankook University, Cheonan 31116, Korea; (H.J.P.); (J.-C.A.)
- College of Medicine, Dankook University, Cheonan 31116, Korea;
| | - Joo Beom Eom
- College of Medicine, Dankook University, Cheonan 31116, Korea;
| | | | | | - Yongdoo Choi
- Research Institute, National Cancer Center, Goyang 10408, Korea;
| | - Jonghyun Eom
- Intelligent Photonic IoT Research Center, Korea Photonics Technology Institute, Gwangju 61007, Korea; (J.C.); (Y.-O.T.)
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12
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Aydin H, Dural AC, Sahbaz NA, Karli M, Guzey D, Akarsu C, Ferahman S, Piskinpasa H, Yegul D, Sipahi M, Koyuncu A, Altinay S, Karabulut M. Clinical adaptation of auxiliary methods and multidisciplinary approach to changing trends in parathyroid surgery. Medicine (Baltimore) 2021; 100:e27160. [PMID: 34596115 PMCID: PMC8483855 DOI: 10.1097/md.0000000000027160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/20/2021] [Indexed: 01/05/2023] Open
Abstract
To examine the effects of multidisciplinary approach and adjunct methods, on the surgical strategy, complications and treatment success of parathyroid surgery.Patients, who were operated for primary hyperparathyroidism (n = 411) at our institution between 2012 and 2019 were reviewed retrospectively. Preoperative imaging studies, surgical method, additional diagnostic methods used during surgery, frozen section results, and histopathology findings, complications, persistence, and recurrence were examined.Localization was determined by first-line examinations in 79.9% (n = 348). Four-dimensional computed tomography was used with an 83.3% success rate. Lateralization success for angiographic selective venous sampling was 80.3% and exact localization success was 65.1%. Bilateral neck exploration was performed in 10.6% (n = 37) of the patients, and in the remaining 89.4% (n = 311), minimally invasive parathyroidectomy (MIP) was performed. While the complication rate was higher in the bilateral neck exploration group (P = .019), persistence and recurrence rates were similar between 2 groups. During the study period, annual case volume increased from 9 cases to 103 cases (P < .001) and the rate of MIP increased from 44.4% to 92.8% over the years (P < .001).Effective use of adjunct techniques has increased the rates of MIP. The multidisciplinary approach has also provided low complication rates with the increasing number of cases.
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Affiliation(s)
- Husnu Aydin
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - A. Cem Dural
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - N. Alper Sahbaz
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Merve Karli
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Deniz Guzey
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Cevher Akarsu
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Sina Ferahman
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Hamide Piskinpasa
- Department of Endocrinology, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Duygu Yegul
- Department of Radiology, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Murat Sipahi
- Department of Nuclear Medicine, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Aysel Koyuncu
- Department of Nuclear Medicine, Faculty of Medicine, Şişli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Serdar Altinay
- Department of Pathology, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Karabulut
- Department of General Surgery, Faculty of Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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13
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Matson J, Lwin TM, Bouvet M. Rapid intraoperative perfusion assessment of parathyroid adenomas with ICG using a wide-field portable hand-held fluorescence imaging system. Am J Surg 2021; 223:686-693. [PMID: 34407918 DOI: 10.1016/j.amjsurg.2021.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/27/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Fluorescence angiography (FA) using indocyanine green dye (ICG) has recently been introduced for real-time identification of parathyroid adenomas. However, time to peak fluorescence has not yet been critically evaluated. METHODS This was a retrospective review of parathyroidectomies with ICG FA over a one-year period. RESULTS There were 66 patients with average age of 64 years. The average time to initial fluorescence was 26.7 s and to peak fluorescence was 38.0 s. The time to saline flush administration significantly correlated with times to initial and peak fluorescence (p < .0001). The rate of in-situ fluorescence was 97%. The rates of suspected adenoma detection were 69% for sestamibi scan, 71% for ultrasound, and 96% for CT scan. Imaging was discordant in 13 cases (20%), with the adenoma located on the opposite side of the neck in 4 cases. CONCLUSIONS ICG FA is a rapid and effective adjunct for the intraoperative identification of parathyroid adenomas.
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Affiliation(s)
- Jared Matson
- Department of Surgery, UC San Diego, San Diego, CA, USA
| | - Thinzar M Lwin
- Department of Surgery, UC San Diego, San Diego, CA, USA; Department of Surgical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | - Michael Bouvet
- Department of Surgery, UC San Diego, San Diego, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA.
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14
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Berber E, Akbulut S. Can near-infrared autofluorescence imaging be used for intraoperative confirmation of parathyroid tissue? J Surg Oncol 2021; 124:1008-1013. [PMID: 34247400 DOI: 10.1002/jso.26603] [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: 05/30/2021] [Revised: 06/22/2021] [Accepted: 06/26/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Whether ex vivo autofluorescence (AF) imaging findings could be quantified to intraoperatively differentiate parathyroid tissue has not been reported. Our aim was to assess the ability of AF imaging to confirm parathyroid tissue during thyroidectomy and parathyroidectomy procedures. METHODS This was a retrospective Institutional Review Board-approved study. AF signals of specimens imaged ex vivo before submission to pathology during thyroidectomy and parathyroidectomy procedures were quantified. Using receiver operating characteristic (ROC) curves, optimal values for sensitivity/specificity to differentiate parathyroid tissue were calculated. RESULTS 166 parathyroid and 217 non-parathyroid specimens were analyzed. With surgical drapes as background, the optimal normalized AF intensity threshold to predict parathyroid tissue on ROC curve analysis was 1.72 (86.1% sensitivity, 84.8% specificity, and area under the curve [AUC]: 0.919). The cutoff for 97% sensitivity was 1.31 and for 99.1% specificity was 3.16. With Telfa as background, the optimal threshold to predict parathyroid tissue was 1.46 (88.4% sensitivity, 76.8% specificity, and AUC: 0.896). The threshold for 96.8% sensitivity was 1.18 and for 98.8% specificity was 2.44. If thresholds for highest specificity were used, 40% of frozen sections to confirm parathyroid tissue could have been avoided. CONCLUSION Quantified brightness analysis of ex vivo AF signals may have utility in intraoperative differentiation of parathyroid tissue for 40% of surgical specimens.
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Affiliation(s)
- Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serkan Akbulut
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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15
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Hu Y, Han AY, Huang S, Pellionisz P, Alhiyari Y, Krane JF, Shori R, Stafsudd O, St John MA. A Tool to Locate Parathyroid Glands Using Dynamic Optical Contrast Imaging. Laryngoscope 2021; 131:2391-2397. [PMID: 34043240 DOI: 10.1002/lary.29633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 05/05/2021] [Accepted: 05/15/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES/HYPOTHESIS Identification of parathyroid glands and adjacent tissues intraoperatively can be quite challenging because of their small size, variable locations, and indistinct external features. The objective of this study is to test the efficacy of the dynamic optical contrast imaging (DOCI) technique as a tool in specifically differentiating parathyroid tissue and adjacent structures, facilitating efficient and reliable tissue differentiation. STUDY DESIGN Prospective study. METHODS Both animal and human tissues were included in this study. Fresh specimens were imaged with DOCI and subsequently processed for hematoxylin and eosin (H&E) stain. The DOCI images were analyzed and compared to the H&E results as ground truth. RESULTS In both animal and human experiments, significant DOCI contrast was observed between parathyroid glands and adjacent tissue of all types. Region of interest analysis revealed most distinct DOCI values for each tissue when using 494 and 572 nm-specific band pass filter for signal detection (P < .005 for porcine tissues, and P = .02 for human specimens). Linear discriminant classifier for tissue type prediction based on DOCI also matched the underlying histology. CONCLUSIONS We demonstrate that the DOCI technique reliably facilitates specific parathyroid gland localization. The DOCI technique constitutes important groundwork for in vivo precision endocrine surgery. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Yong Hu
- Department of Head and Neck Surgery, University of California Los Angeles (UCLA), Los Angeles, California, U.S.A
| | - Albert Y Han
- Department of Head and Neck Surgery, University of California Los Angeles (UCLA), Los Angeles, California, U.S.A.,UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, California, U.S.A.,Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, California, U.S.A
| | - Shan Huang
- Department of Materials Science and Engineering, UCLA, Los Angeles, California, U.S.A
| | - Peter Pellionisz
- Department of Biomedical Engineering, UCLA, Los Angeles, California, U.S.A
| | - Yazeed Alhiyari
- Department of Head and Neck Surgery, University of California Los Angeles (UCLA), Los Angeles, California, U.S.A
| | - Jeffrey F Krane
- Department of Pathology and Laboratory Medicine, UCLA Medical Center, Los Angeles, California, U.S.A
| | - Ramesh Shori
- Department of Electrical and Computer Engineering, Henry Samueli School of Engineering, UCLA, Los Angeles, California, U.S.A
| | - Oscar Stafsudd
- Department of Electrical and Computer Engineering, Henry Samueli School of Engineering, UCLA, Los Angeles, California, U.S.A
| | - Maie A St John
- Department of Head and Neck Surgery, University of California Los Angeles (UCLA), Los Angeles, California, U.S.A.,UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, California, U.S.A.,Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, California, U.S.A.,Department of Pathology and Laboratory Medicine, UCLA Medical Center, Los Angeles, California, U.S.A
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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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17
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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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18
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Spartalis E, Ntokos G, Georgiou K, Zografos G, Tsourouflis G, Dimitroulis D, Nikiteas NI. Intraoperative Indocyanine Green (ICG) Angiography for the Identification of the Parathyroid Glands: Current Evidence and Future Perspectives. In Vivo 2020; 34:23-32. [PMID: 31882459 DOI: 10.21873/invivo.11741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 11/16/2019] [Accepted: 11/25/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM Recently, indocyanine green (ICG) fluorescence imaging has been used for the identification of the parathyroid glands (PG) during thyroid and parathyroid surgery. However, an overall consensus on the optimal technique, the dosage, the timing of the ICG administration and finally its interpretation and clinical usefulness is still lacking evidence. The aim of this review is to investigate the use of ICG angiography during thyroidectomy and/or parathyroidectomy for identification as well as for the perfusion integrity of the parathyroid glands. MATERIALS AND METHODS The PubMed database was systematically searched for publications regarding intraoperative ICG imaging in patients that undergo thyroidectomy or parathyroidectomy. RESULTS Eighteen publications reporting on 612 patients, namely 71 parathyroidectomy and 541 thyroidectomy patients met the inclusion criteria. Eleven publications reported the use of ICG angiography for the identification of the parathyroid glands during thyroidectomy and seven during parathyroidectomy for primary and secondary hyperparathyroidism. CONCLUSION ICG fluorescence imaging is a simple, fast and reproducible method capable of intraoperatively visualizing and assessing the function of parathyroid glands, and can, therefore, assist surgeons in their decision-making. Despite all this, ICG fluorescence imaging technique for PG detection still lacks standardization and further studies are needed to establish its clinical utility.
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Affiliation(s)
- Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens Medical School, Athens, Greece .,Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece
| | - Georgios Ntokos
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,3rd Surgical Department, "George Gennimatas" General Hospital, Athens, Greece
| | - Konstantinos Georgiou
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Georgios Zografos
- 3rd Surgical Department, "George Gennimatas" General Hospital, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Nikolaos I Nikiteas
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens Medical School, Athens, Greece.,Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece
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19
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Intraoperative Adjunct Methods for Localization in Primary Hyperparathyroidism. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 53:84-95. [PMID: 32377064 PMCID: PMC7199831 DOI: 10.14744/semb.2019.37542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 12/16/2022]
Abstract
Primary hyperparathyroidism (pHPT) is a frequently seen endocrine disease, and its main treatment is surgery. In the majority of pHPT, the disease involves only a single gland, and the majority of the pathological glands can be determined by preoperative localization methods.In addition to preoperative localization studies in parathyroidectomy, the use of adjunct methods to improve intraoperative localization in order to increase success of surgery is becoming widespread. These methods include different approaches, mainly intraoperative parathyroid hormone (PTH) measurement, followed by intraoperative gamma probe application, intraoperative ultrasonography, parathyroid imaging with methylene blue, and frozen section examination. Recently, especially promising new imaging methods have been described in the literature with various optical technologies to increase the localization of the parathyroid glands and to evaluate their viability. These methods include parathyroid imaging with autofluorescence, indocyanine green imaging with autofluorescence, autofluorescence imaging with methylene blue, autofluorescence imaging with 5-aminolevulinic acid, optical coherence tomography, laser speckle contrast imaging, dynamic optical contrast imaging, and Raman spectroscopy. Currently, minimally invasive parathyroidectomy has become the standard treatment for selected pHPT patients with the aid of preoperative imaging and intraoperative auxiliary methods . The aim of the present study was to evaluate the routinely used new promising intraoperative adjunct methods in pHPT.
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20
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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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21
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Liu J, Wang X, Wang R, Xu C, Zhao R, Li H, Zhang S, Yao X. Near-infrared auto-fluorescence spectroscopy combining with Fisher's linear discriminant analysis improves intraoperative real-time identification of normal parathyroid in thyroidectomy. BMC Surg 2020; 20:4. [PMID: 31907042 PMCID: PMC6945439 DOI: 10.1186/s12893-019-0670-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the efficacy of a sensitive, real-time tool for identification and protection for parathyroid glands during thyroidectomy. METHODS Near-infrared (NIR) auto-fluorescence was measured intraoperatively from 20 patients undergoing thyroidectomy. Spectra were measured from suspicious parathyroid glands and surrounding neck tissues during the operation with a NIR fluorescence system. Fast frozen sections were performed on the suspicious parathyroid glands. Accuracy was evaluated by comparison with histology and NIR identification. Data were attracted for Fisher's linear discriminant analysis. RESULTS The auto-fluorescence intensity of parathyroid was significantly higher than that of thyroid, fat and lymph node. The peak intensity of auto-fluorescence from parathyroid was 5.55 times of that from thyroid at the corresponding wave number. Of the 20 patients, the parathyroid was accurately detected and identified in 19 patients by NIR system, compared with their histologic results. One suspicious parathyroid did not exhibit typical spectra, and was proved to be fat tissue by histology. The NIR auto-fluorescence method had a 100% sensitivity of parathyroid glands identification and a high accuracy of 95%. The positive predictive value was 95%. The parathyroid gland have specific auto-fluorescence spectrum and can be separated from the other three samples through the Fisher's linear discriminant analysis. CONCLUSIONS NIR auto-fluorescence spectroscopy can accurately identify normal parathyroid gland during thyroidectomy. The Fisher's linear discriminant analysis demonstrated the specificity of the NIR auto-fluorescence of parathyroid tissue and its efficacy in parathyroid discrimination.
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Affiliation(s)
- Junsong Liu
- Department of Otorhinolaryngology-Head and Neck Surgery, 277 West Yanta Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xiaoxia Wang
- Department of Otorhinolaryngology, Air Force 986 Hospital of Chinese People's Liberation Army, Xi'an, Shaanxi, 710054, People's Republic of China
| | - Rui Wang
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Chongwen Xu
- Department of Otorhinolaryngology-Head and Neck Surgery, 277 West Yanta Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Ruimin Zhao
- Department of Otorhinolaryngology-Head and Neck Surgery, 277 West Yanta Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Honghui Li
- Department of Otorhinolaryngology-Head and Neck Surgery, 277 West Yanta Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Shaoqiang Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, 277 West Yanta Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xiaobao Yao
- Department of Otorhinolaryngology-Head and Neck Surgery, 277 West Yanta Road, Xi'an, Shaanxi, 710061, People's Republic of China.
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22
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Rudin AV, McKenzie TJ, Thompson GB, Farley DR, Lyden ML. Evaluation of Parathyroid Glands with Indocyanine Green Fluorescence Angiography After Thyroidectomy. World J Surg 2019; 43:1538-1543. [PMID: 30659346 DOI: 10.1007/s00268-019-04909-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow. This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide autotransplantation and potentially decrease permanent hypoparathyroidism. METHODS This was a retrospective study of patients who underwent total or near-total thyroidectomy (T-NT) between January 2015 and March 2018. Patients with preoperative hyperparathyroidism and those undergoing reoperation were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. Data were analyzed to assess the frequency of autotransplantation and incidence of hypoparathyroidism between groups. RESULTS In total, 210 patients underwent T-NT: 86 with ICGA and 124 without. Autotransplantation was more common in the ICGA group at 36% compared to 12% in the control (p = 0.0001). There was no correlation with at least one normal parathyroid gland on ICGA and postoperative PTH levels (p = 0.75). There was a difference in having normal postoperative PTH when there were at least two normal parathyroid glands (n = 50) compared to patients with less than two normal ICGA glands (n = 36, p = 0.044). Visual assessment and ICGA assessment of vascularity were in agreement, 245/281 (87%). There were 19 glands (6.8%) that would have undergone autotransplant based on visual inspection that had adequate blood supply on ICGA. Transient hypoparathyroidism was present in 45 out of 124 controls (36%) and 32 out of 86 (37%) in the ICG group. CONCLUSIONS ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection. ICGA can guide more appropriate autotransplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.
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Affiliation(s)
- Anatoliy V Rudin
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Travis J McKenzie
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Geoffrey B Thompson
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - David R Farley
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Melanie L Lyden
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA.
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23
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Jin H, Cui M. New Advances of ICG Angiography in Parathyroid Identification. Endocr Metab Immune Disord Drug Targets 2019; 19:936-940. [PMID: 30727933 DOI: 10.2174/1871530319666190206212456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/05/2019] [Accepted: 01/19/2019] [Indexed: 12/27/2022]
Abstract
Objective:
For surgeons, locating parathyroid in thyroidectomy and parathyroidectomy is
critical since parathyroid plays an important role in calcium balance. The fluorescence of parathyroid
has already been found by researchers and the angiography equipment detecting the fluorescence of
parathyroid with indocyanine green has been widely applied. Using the indocyanine green angiography
and looking at the actual fluorescence of in vivo and in vitro tissues, it was possible to identify thyroid,
parathyroid, lymph nodes and fat tissues during the surgical procedure. This mini-review aims to present
the application of indocyanine green angiography in parathyroid detection and discusses the safety
of this method.
Methods:
The relevant data were searched by using the keywords “Indocyanine green,” “Parathyroid,”
and “Identification” and “Protection” in “Pubmed,” “Web of Science” and “China Knowledge Resource
Integrated databases”, and a manual search was done to acquire peer-reviewed articles and reports
about indocyanine green.
Results:
Indocyanine green dye along with the intraoperative fluorescence imaging system is safe in
detecting parathyroid and predicting postoperative hypoparathyroidism.
Conclusion:
The conclusion suggests that indocyanine green angiography is a safe, effective and easy
way to detect parathyroid glands. The conclusion will be of interest to surgeons regarding thyroidectomy
and parathyroidectomy.
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Affiliation(s)
- Hao Jin
- The Second Department of General Surgery, Zhuhai People’s Hospital, No. 79 of Kangning Road, Xiangzhou District, Zhuhai City, Guangdong Province, 519000, China
| | - Min Cui
- The Second Department of General Surgery, Zhuhai People’s Hospital, No. 79 of Kangning Road, Xiangzhou District, Zhuhai City, Guangdong Province, 519000, China
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24
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Aygün N, Uludağ M. Surgical Treatment of Primary Hyperparathyroidism: Which Therapy to Whom? SISLI ETFAL HASTANESI TIP BULTENI 2019; 53:201-214. [PMID: 32377085 PMCID: PMC7192265 DOI: 10.14744/semb.2019.56873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
Primary hyperparathyroidism (pHPT) is characterized by an increase in the levels of PTH and Ca, or one of these (Ca, PTH) as a result of a dysregulation of calcium (Ca) metabolism due to inappropriate excess parathyroid hormone (PTH) autonomously produced from one or more than one parathyroid glands. Ninety to 95% of pHPT is a sporadic type, which is not associated with the familial history and other endocrine organ tumors, and 5-10% of it is hereditary. While 80-85% of pHPT arises from a single parathyroid adenoma, 4-5% is caused by a double adenoma, 10-15% by multigland hyperplasia and less than 1% by parathyroid cancer. The diagnosis of pHPT is reached biochemically. The only curative treatment of pHPT is surgery. The choice of surgery in pHPT may vary depending on whether the patient has hereditary HPT or thyroid disease requiring surgical treatment, preoperative localization studies and the findings in these studies, the possibilities of using intraoperative PTH and the preference of the surgeon. The preoperatively determined surgical strategy can be revised according to intraoperative findings in case of need to achieve excellent results. The two main approaches in the surgical treatment of pHPT are BNE (bilateral neck exploration) and MIP (minimal invasive parathyroidectomy). Although BNE is a consistently valid option that has excellent results in the surgical treatment of pHPT and is considered the gold standard, MIP is the ideal approach in selected patients with clinically and radiologically considered a single-gland disease. Negative imaging is not a contraindication for parathyroid surgery and is not a criterion for the presence or absence of surgical indication. Although both methods are safe and effective in the surgical treatment of sporadic pHPT, there is still controversy regarding the effectiveness of both methods. Surgical intervention should establish the risk-benefit balance well, minimize the risk of persistent and recurrent disease and provide the highest cure rate without increasing the risk of complications. Complication rates are higher in the secondary surgery, thus in secondary procedures, selective surgery should be performed under guidance of an imaging modality. The surgical strategy should be determined to achieve maximum cure with minimum dissection and minimal morbidity. In this study, we aimed to determine the type of surgical treatment and pHPT patients suitable for the surgical treatment.
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Affiliation(s)
- Nurcihan Aygün
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Uludağ
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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25
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Rudin AV, Berber E. Impact of fluorescence and autofluorescence on surgical strategy in benign and malignant neck endocrine diseases. Best Pract Res Clin Endocrinol Metab 2019; 33:101311. [PMID: 31494052 DOI: 10.1016/j.beem.2019.101311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Fluorescence and autofluorescence have been shown by several recent studies to be valuable adjuncts in identifying parathyroid glands during thyroidectomy and parathyroidectomy. The aim of this chapter is to review the impact of this new technology on surgical strategy concerning identification and preservation of parathyroid glands during thyroidectomy, identification of parathyroid glands in hyperparathyroidism, and the potential role in thyroid cancer surgery.
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Affiliation(s)
- Anatoliy V Rudin
- Department of Endocrine Surgery, Cleveland Clinic, United States
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, United States; Department of General Surgery, Cleveland Clinic, United States.
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26
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Squires MH, Jarvis R, Shirley LA, Phay JE. Intraoperative Parathyroid Autofluorescence Detection in Patients with Primary Hyperparathyroidism. Ann Surg Oncol 2019; 26:1142-1148. [DOI: 10.1245/s10434-019-07161-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Indexed: 11/18/2022]
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27
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van den Bos J, van Kooten L, Engelen SME, Lubbers T, Stassen LPS, Bouvy ND. Feasibility of indocyanine green fluorescence imaging for intraoperative identification of parathyroid glands during thyroid surgery. Head Neck 2018; 41:340-348. [PMID: 30536963 PMCID: PMC6590433 DOI: 10.1002/hed.25451] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/23/2018] [Accepted: 08/15/2018] [Indexed: 12/16/2022] Open
Abstract
Background This study assessed the feasibility of near‐infrared fluorescence imaging with indocyanine green (ICG) to identify the parathyroid glands (PGs) intraoperatively and to assess their perfusion after thyroid resection. Methods Patients undergoing elective thyroidectomy were enrolled in this prospective study. An intravenous bolus of 7.5 mg ICG was administered twice: the first bolus to identify the PGs before resection of the thyroid and the second to assess vascularization of the PGs after resection. Results A total of 30 operations in 26 patients were included. In 17 surgeries (56.7%), fluorescence imaging was of added value, especially to confirm the presence of a suspected PG. No intraoperative or postoperative complications occurred because of the use of ICG. Conclusion Near‐infrared fluorescence imaging with the use of ICG for intraoperative identification of the PGs and the assessment of its vascularization is feasible and safe and can provide more certainty about the location of the PGs.
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Affiliation(s)
- Jacqueline van den Bos
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Lottie van Kooten
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Sanne M E Engelen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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28
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Abbaci M, De Leeuw F, Breuskin I, Casiraghi O, Lakhdar AB, Ghanem W, Laplace-Builhé C, Hartl D. Parathyroid gland management using optical technologies during thyroidectomy or parathyroidectomy: A systematic review. Oral Oncol 2018; 87:186-196. [PMID: 30527238 DOI: 10.1016/j.oraloncology.2018.11.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023]
Abstract
New optical technologies enhancing localization or assessing viability of parathyroid glands (PG) during endocrine surgery have been reported in clinical studies. These technologies could become complementary to the surgeon's eyes and may improve surgical outcomes in thyroidectomy and parathyroidectomy. Here, we conducted a systematic review focusing on PG identification and functional assessment using optical methods to enhance surgery. A systematic literature review was performed using MEDLINE and Embase database. Two authors selected studies and extracted data; qualitative analysis was performed to summarize the characteristics of reported optical tools for thyroidectomy or parathyroidectomy. Identification and vascularisation of PG during surgery were evaluated. Clinical and biochemical outcomes were appraised when reported. Studies relating to parathyroidectomy or thyroidectomy combined with autofluorescence, fluorescent methylene blue, 5-aminolevulinic acid, indocyanine green (ICG), optical coherence tomography, laser speckle contrast imaging, dynamic optical contrast imaging and Raman spectroscopy were identified with MEDLINE and Embase. We included a total of 47 relevant articles with a total of 1615 patients enrolled. Each optical technique is described and appreciated related to its surgical purpose. Autofluorescence and ICG imaging of PG are the most widely reported optical technologies for identification and assessment of vascularisation of PG. Results are mainly based on observational studies and argue for the feasibility of both techniques in endocrine surgery but prospective randomized studies have not been performed. In vivo applications are still limited for the other methods and further investigations correlating these techniques with post-operative parathormone measurements are still needed before considering these technologies in clinical practice.
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Affiliation(s)
- Muriel Abbaci
- Gustave Roussy, Université Paris-Saclay, Plate-forme Imagerie et Cytométrie, UMS 23/3655, Villejuif F-94805, France; IR4M-UMR 8081, Université Paris-Saclay, Université Paris Sud, CNRS, Orsay F-91401, France.
| | - Frederic De Leeuw
- Gustave Roussy, Université Paris-Saclay, Plate-forme Imagerie et Cytométrie, UMS 23/3655, Villejuif F-94805, France
| | - Ingrid Breuskin
- Gustave Roussy, Université Paris-Saclay, Départements de Cancérologie et de Chirurgie Cervico-Faciale, Villejuif F-94805, France
| | - Odile Casiraghi
- Gustave Roussy, Université Paris-Saclay, Département de Biologie et Pathologie Médicale, Villejuif F-94805, France
| | - Aïcha Ben Lakhdar
- Gustave Roussy, Université Paris-Saclay, Département de Biologie et Pathologie Médicale, Villejuif F-94805, France
| | - Wahib Ghanem
- Gustave Roussy, Université Paris-Saclay, Départements de Cancérologie et de Chirurgie Cervico-Faciale, Villejuif F-94805, France
| | - Corinne Laplace-Builhé
- Gustave Roussy, Université Paris-Saclay, Plate-forme Imagerie et Cytométrie, UMS 23/3655, Villejuif F-94805, France; IR4M-UMR 8081, Université Paris-Saclay, Université Paris Sud, CNRS, Orsay F-91401, France
| | - Dana Hartl
- Gustave Roussy, Université Paris-Saclay, Départements de Cancérologie et de Chirurgie Cervico-Faciale, Villejuif F-94805, France
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29
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Bonnin-Pascual J, Álvarez-Segurado C, Jiménez-Segovia M, Bianchi A, Bonnin-Pascual F, Molina-Romero FX, González-Argente FX. Aportaciones de la fluorescencia a la cirugía endocrina. Cir Esp 2018; 96:529-536. [DOI: 10.1016/j.ciresp.2018.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/05/2018] [Accepted: 09/12/2018] [Indexed: 02/06/2023]
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30
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Orloff LA, Wiseman SM, Bernet VJ, Fahey TJ, Shaha AR, Shindo ML, Snyder SK, Stack BC, Sunwoo JB, Wang MB. American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults. Thyroid 2018; 28:830-841. [PMID: 29848235 DOI: 10.1089/thy.2017.0309] [Citation(s) in RCA: 227] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment. SUMMARY HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.
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Affiliation(s)
- Lisa A Orloff
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Sam M Wiseman
- 2 Department of Surgery, University of British Columbia , Vancouver, Canada
| | - Victor J Bernet
- 3 Division of Endocrinology, Mayo Clinic College of Medicine , Jacksonville, Florida
| | - Thomas J Fahey
- 4 Department of Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center , New York, New York
| | - Ashok R Shaha
- 5 Head and Neck Service, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Maisie L Shindo
- 6 Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University , Portland, Oregon
| | - Samuel K Snyder
- 7 Department of Surgery, University of Texas Rio Grande Valley School of Medicine , Harlingen, Texas
| | - Brendan C Stack
- 8 Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - John B Sunwoo
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Marilene B Wang
- 9 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA , Los Angeles, California
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31
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DeLong JC, Ward EP, Lwin TM, Brumund KT, Kelly KJ, Horgan S, Bouvet M. Indocyanine green fluorescence-guided parathyroidectomy for primary hyperparathyroidism. Surgery 2018; 163:388-392. [PMID: 29129358 PMCID: PMC11060843 DOI: 10.1016/j.surg.2017.08.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/06/2017] [Accepted: 08/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Our aim was to evaluate the ease and utility of using indocyanine green fluorescence angiography for intraoperative localization of the parathyroid glands. METHODS Indocyanine green fluorescence angiography was performed during 60 parathyroidectomies for primary hyperparathyroidism during a 22-month period. Indocyanine green was administered intravenously to guide operative navigation using a commercially available fluorescence imaging system. Video files were graded by 3 independent surgeons for strength of enhancement using an adapted numeric scoring system. RESULTS There were 46 (77%) female patients and 14 (23%) male patients whose ages ranged from 17 to 87 (average 60) years old. Of the 60 patients, 43 (71.6%) showed strong enhancement, 13 (21.7%) demonstrated mild to moderate vascular enhancement, and 4 (6.7%) exhibited little or no vascular enhancement. Of the 54 patients who had a preoperative sestamibi scan, a parathyroid adenoma was identified in 36, while 18 failed to localize. Of the 18 patients who failed to localize, all 18 patients (100%) had an adenoma that fluoresced on indocyanine green imaging. The operations were performed safely with minimal blood loss and short operative times. CONCLUSION Indocyanine green angiography has the potential to assist surgeons in identifying parathyroid glands rapidly with minimal risk.
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Affiliation(s)
- Jonathan C DeLong
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Erin P Ward
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Thinzar M Lwin
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Kevin T Brumund
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Kaitlyn J Kelly
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Santiago Horgan
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Michael Bouvet
- Department of Surgery, University of California San Diego, San Diego, CA.
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32
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Chang YK, Lang BHH. To identify or not to identify parathyroid glands during total thyroidectomy. Gland Surg 2017; 6:S20-S29. [PMID: 29322019 DOI: 10.21037/gs.2017.06.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hypoparathyroidism is one of the most common complications after total thyroidectomy and may impose a significant burden to both the patient and clinician. The extent of thyroid resection, surgical techniques, concomitant central neck dissection, parathyroid gland (PG) autotransplantation and inadvertent parathyroidectomy have long been some of the risk factors for postoperative hypoparathyroidism. Although routine identification of PGs has traditionally been advocated by surgeons, recent evidence has suggested that perhaps identifying fewer number of in situ PGs during surgery (i.e., selective identification) may further lower the risk of hypoparathyroidism. One explanation is that visual identification may often lead to subtle damages to the nearby blood supply of the in situ PGs and that may increase the risk of hypoparathyroidism. However, it is worth highlighting the current literature supporting either approach (i.e., routine vs. selective) remains scarce and because of the significant differences in study design, inclusions, definitions and management protocol between studies, a pooled analysis on this important but controversial topic remains an impossible task. Furthermore, it is worth nothing that identification of PGs does not equal safe preservation, as some studies demonstrated that it is not the number of PGs identified, but the number of PG preserved in situ that matters. Therefore a non-invasive, objective and reliable way to localize PGs and assess their viability intra-operatively is warranted. In this aspect, modern technology such as the indocyanine green (ICG) as near-infrared fluorescent dye for real-time in situ PG perfusion monitoring may have a potential role in the future.
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Affiliation(s)
- Yuk Kwan Chang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Brian H H Lang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
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33
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Kahramangil B, Berber E. Comparison of indocyanine green fluorescence and parathyroid autofluorescence imaging in the identification of parathyroid glands during thyroidectomy. Gland Surg 2017; 6:644-648. [PMID: 29302480 DOI: 10.21037/gs.2017.09.04] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Indocyanine green fluorescence (ICGF) and parathyroid autofluorescence (AF) are two new techniques that aid in the identification of parathyroid glands (PG) intraoperatively during thyroidectomy. There is no study comparing the efficacy of these techniques. Methods This was an IRB-approved clinical study comparing the utility of ICGF and AF for identification of PGs during thyroidectomy. Data were collected prospectively. Both techniques were compared to naked eye (NE) for PG detection. Standard statistical methods were used for data analysis. Results Twenty-two patients in each group underwent a total of 39 total thyroidectomies and 5 thyroid lobectomies. AF and ICGF had similar detection rates for PGs [98% (61 of 62) and 95% (60 of 63) of PGs, respectively; P=0.31]. The location of PGs was suggested before detection with NE more frequently by AF than ICGF [52% (32 of 62) vs. 6% (4 of 63) of PGs; P<0.001]. In 82% (18 of 22) of patients at least one PG was detected by AF before NE, as opposed to 14% (3 of 22) by ICGF (P<0.001). The median (range) number of PGs detected before NE per patient was greater with AF than ICGF [2 (0-3) vs. 0 (0-2)];. Upper PGs were more likely to be detected by AF before recognition with NE than the lower ones (P=0.03). There was no predictive factor for ICGF detection. Postoperative hypocalcemia rates were similar [9% (2 of 22) and 5% (1 of 22) for AF and ICGF, respectively; P>0.99]. Conclusions To the best of our knowledge, this is the first comparative study between parathyroid AF and ICGF in detection of PGs during thyroidectomy. Our data suggest both techniques have similarly high detection rates and that the main difference lies in the timing of detection. AF more frequently detects PGs before recognition with NE compared to ICGF.
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Affiliation(s)
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, OH, USA
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34
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Jitpratoom P, Anuwong A. The use of ICG enhanced fluorescence for the evaluation of parathyroid gland preservation. Gland Surg 2017; 6:579-586. [PMID: 29142851 DOI: 10.21037/gs.2017.09.01] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Indocyanine green (ICG) enhanced fluorescence imaging is recent innovation as the "real-time intraoperative imaging" technique. Many clinical studies have been reported in the literature which use different devices and techniques that employ various doses and usages of ICG as a non-specific contrast agent. Several groups have performed studies in endocrine surgery, especially with regards to parathyroid-related outcomes after thyroid and parathyroid surgery. However, there is no consensus on the technical details that should be applied. With this study, we aimed to review the current literature on potential use of intraoperative ICG angiography for evaluating parathyroid gland (PTG) preservation.
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Affiliation(s)
| | - Angkoon Anuwong
- Department of Surgery, Police General Hospital, Bangkok, Thailand
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35
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Kim SW, Lee HS, Lee KD. Intraoperative real-time localization of parathyroid gland with near infrared fluorescence imaging. Gland Surg 2017; 6:516-524. [PMID: 29142843 DOI: 10.21037/gs.2017.05.08] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgeons have cited difficulties in identifying the parathyroid glands (PG) during thyroidectomy. To overcome the limitation of naked eye, many studies on near-infrared fluorescence imaging of PGs have been introduced and suggested that fluorescence imaging is useful for both localizing PGs and evaluating their function. This imaging technique has been reported in two ways: (I) imaging using a fluorescent material called indocyanine green (ICG); and (II) autofluorescence using intrinsic fluorophores. These innovative and novel techniques are expected to have a significant impact on performing thyroid or parathyroid surgery. In this article, current papers that describe ICG fluorescence and autofluorescence imaging of PG during thyroid and parathyroid surgery are reviewed.
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Affiliation(s)
- Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, South Korea
| | - Hyoung Shin Lee
- Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, South Korea
| | - Kang Dae Lee
- Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, South Korea
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Increased identification of parathyroid glands using near infrared light during thyroid and parathyroid surgery. Surg Endosc 2017; 31:3737-3742. [PMID: 28364157 DOI: 10.1007/s00464-017-5424-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 01/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Parathyroid gland (PG) identification during thyroid and parathyroid surgery is challenging. Accidental parathyroidectomy increases the rate of postoperative hypocalcaemia. Recently, autofluorescence with near infrared light (NIRL) has been described for PG visualization. The aim of this study is to analyze the increased rate of visualization of PGs with the use of NIRL compared to white light (WL). MATERIALS AND METHODS All patients undergoing thyroid and parathyroid surgery were included in this study. PGs were identified with both NIRL and WL by experienced head and neck surgeons. The number of PGs identified with NIRL and WL were compared. The identification of PGs was correlated to age, sex, and histopathological diagnosis. RESULTS Seventy-four patients were included in the study. The mean age was 48.4 (SD ±13.5) years old. Mean PG fluorescence intensity (47.60) was significantly higher compared to the thyroid gland (22.32) and background (9.27) (p < 0.0001). The mean number of PGs identified with NIRL and WL were 3.7 and 2.5 PG, respectively (p < 0.001). The difference in the number of PGs identified with NIRL and WL and fluorescence intensity was not related to age, sex, or histopathological diagnosis, with the exception of the diagnosis of thyroiditis, in which there was a significant increase in the number of PGs visualized with NIRL (p = 0.026). CONCLUSION The use of NIRL for PG visualization significantly increased the number of PGs identified during thyroid and parathyroid surgery, and the differences in fluorescent intensity among PGs, thyroid glands, and background were not affected by age, sex, and histopathological diagnosis.
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Kahramangil B, Berber E. The use of near-infrared fluorescence imaging in endocrine surgical procedures. J Surg Oncol 2017; 115:848-855. [PMID: 28205245 DOI: 10.1002/jso.24583] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 01/30/2017] [Indexed: 12/22/2022]
Abstract
Near-infrared fluorescence imaging in endocrine surgery is a new, yet highly investigated area. It involves indocyanine green use as well as parathyroid autofluorescence. Several groups have described their technique and reported on the observed utility. However, there is no consensus on technical details. Furthermore, the correlation between intraoperative findings and postoperative outcomes is unclear. With this study, we aim to review the current literature on fluorescence imaging and share our insights on technical details.
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Affiliation(s)
- Bora Kahramangil
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
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Takahashi H, Zaidi N, Berber E. An initial report on the intraoperative use of indocyanine green fluorescence imaging in the surgical management of liver tumorss. J Surg Oncol 2016; 114:625-629. [DOI: 10.1002/jso.24363] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 06/25/2016] [Indexed: 12/31/2022]
Affiliation(s)
| | - Nisar Zaidi
- Department of Endocrine Surgery; Cleveland Clinic; Ohio
| | - Eren Berber
- Department of General Surgery; Cleveland Clinic; Ohio
- Department of Endocrine Surgery; Cleveland Clinic; Ohio
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Colvin J, Zaidi N, Berber E. The utility of indocyanine green fluorescence imaging during robotic adrenalectomy. J Surg Oncol 2016; 114:153-6. [PMID: 27189336 DOI: 10.1002/jso.24296] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/02/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Indocyanine green (ICG) has been used for medical imaging since 1950s, but has more recently become available for use in minimally invasive surgery owing to improvements in technology. This study investigates the use of ICG florescence to guide an accurate dissection by delineating the borders of adrenal tumors during robotic adrenalectomy (RA). METHODS This prospective study compared conventional robotic view with ICG fluorescence imaging in 40 consecutive patients undergoing RA. Independent, non-blinded observers assessed how accurately ICG fluorescence delineated the borders of adrenal tumors compared to conventional robotic view. RESULTS A total of 40 patients underwent 43 adrenalectomies. ICG imaging was superior, equivalent, or inferior to conventional robotic view in 46.5% (n = 20), 25.6% (n = 11), and 27.9% (n = 12) of the procedures. On univariate analysis, the only parameter that predicted the superiority of ICG imaging over conventional robotic view was the tumor type, with adrenocortical tumors being delineated more accurately on ICG imaging compared to conventional robotic view. CONCLUSIONS This study demonstrates the utility of ICG to guide the dissection and removal of adrenal tumors during RA. A simple reproducible method is reported, with a detailed description of the utility based on tumor type, approach and side. J. Surg. Oncol. 2016;114:153-156. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jennifer Colvin
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nisar Zaidi
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eren Berber
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio.,Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
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Zaidi N, Bucak E, Yazici P, Soundararajan S, Okoh A, Yigitbas H, Dural C, Berber E. The feasibility of indocyanine green fluorescence imaging for identifying and assessing the perfusion of parathyroid glands during total thyroidectomy. J Surg Oncol 2016; 113:775-8. [PMID: 27041628 DOI: 10.1002/jso.24237] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND There are limited adjuncts available for identifying and assessing the viability of parathyroid glands (PGs) during total thyroidectomy (TT). The aim of this study is to determine the feasibility of indocyanine green (ICG) imaging in identifying and assessing perfusion of PGs during TT. METHODS ICG was administered in patients undergoing TT and fluorescence of PGs was assessed. A grading scale was developed for assessing degree of ICG uptake. Patients were evaluated for hypocalcemia and hypoparathyroidism on post-operative day (POD) #1. RESULTS Twenty-seven patients underwent TT with ICG imaging for multinodular goiter (n = 13), thyroid cancer (n = 10), and Graves' disease (n = 4). Eight-five PGs were identified visually, 71 (84%) of which showed ICG fluorescence. False negative rate was 6%. Post-operatively, three patients (11%) had a serum calcium value <8 mg/dl. ICG uptake after TT correlated with post-operative PTH levels: mean POD#1 PTH of those patients with at least two PGs exhibiting <30% fluorescence was 9 pg/ml; whereas those with fewer than two demonstrating <30% fluorescence had a POD#1 PTH of 19.5 pg/ml (P = 0.05). CONCLUSION ICG imaging of PGs during TT is feasible. ICG might be a useful adjunct in identifying those patients at risk for post-thyroidectomy hypoparathyroidism. J. Surg. Oncol. 2016;113:775-778. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Nisar Zaidi
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Emre Bucak
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Pinar Yazici
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Alexis Okoh
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Hakan Yigitbas
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Cem Dural
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
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