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Wang B, Zhou CP, Ao W, Cai SJ, Ge ZW, Wang J, Huang WY, Yu JF, Wu SB, Yan SY, Zhang LY, Wang SS, Wang ZH, Hua S, Abdelhamid Ahmed AH, Randolph GW, Zhao WX. Exploring near-infrared autofluorescence properties in parathyroid tissue: an analysis of fresh and paraffin-embedded thyroidectomy specimens. JOURNAL OF BIOMEDICAL OPTICS 2025; 30:S13702. [PMID: 39034960 PMCID: PMC11256002 DOI: 10.1117/1.jbo.30.s1.s13702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/23/2024]
Abstract
Significance Near-infrared autofluorescence (NIRAF) utilizes the natural autofluorescence of parathyroid glands (PGs) to improve their identification during thyroid surgeries, reducing the risk of inadvertent removal and subsequent complications such as hypoparathyroidism. This study evaluates NIRAF's effectiveness in real-world surgical settings, highlighting its potential to enhance surgical outcomes and patient safety. Aim We evaluate the effectiveness of NIRAF in detecting PGs during thyroidectomy and central neck dissection and investigate autofluorescence characteristics in both fresh and paraffin-embedded tissues. Approach We included 101 patients diagnosed with papillary thyroid cancer who underwent surgeries in 2022 and 2023. We assessed NIRAF's ability to locate PGs, confirmed via parathyroid hormone assays, and involved both junior and senior surgeons. We measured the accuracy, speed, and agreement levels of each method and analyzed autofluorescence persistence and variation over 10 years, alongside the expression of calcium-sensing receptor (CaSR) and vitamin D. Results NIRAF demonstrated a sensitivity of 89.5% and a negative predictive value of 89.1%. However, its specificity and positive predictive value (PPV) were 61.2% and 62.3%, respectively, which are considered lower. The kappa statistic indicated moderate to substantial agreement (kappa = 0.478; P < 0.001 ). Senior surgeons achieved high specificity (86.2%) and PPV (85.3%), with substantial agreement (kappa = 0.847; P < 0.001 ). In contrast, junior surgeons displayed the lowest kappa statistic among the groups, indicating minimal agreement (kappa = 0.381; P < 0.001 ). Common errors in NIRAF included interference from brown fat and eschar. In addition, paraffin-embedded samples retained stable autofluorescence over 10 years, showing no significant correlation with CaSR and vitamin D levels. Conclusions NIRAF is useful for PG identification in thyroid and neck surgeries, enhancing efficiency and reducing inadvertent PG removals. The stability of autofluorescence in paraffin samples suggests its long-term viability, with false positives providing insights for further improvements in NIRAF technology.
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Affiliation(s)
- Bo Wang
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
- Fujian Clinical Research Center for Precision Management of Thyroid Cancers, Fuzhou, China
- Harvard Medical School, Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States
| | - Chi-Peng Zhou
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
- Fujian Clinical Research Center for Precision Management of Thyroid Cancers, Fuzhou, China
| | - Wei Ao
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Shao-Jun Cai
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Zhi-Wen Ge
- Fujian Medical University Union Hospital, Department of Pathology, Fuzhou, China
| | - Jun Wang
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Wen-Yu Huang
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Jia-Fan Yu
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Si-Bin Wu
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Shou-Yi Yan
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Li-Yong Zhang
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Si-Si Wang
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
| | - Zhi-hong Wang
- The First Affiliated Hospital of China Medical University, Department of Thyroid Surgery, Shenyang, China
| | - Surong Hua
- Peking Union Medical College, Department of General Surgery, Peking, China
| | - Amr H. Abdelhamid Ahmed
- Harvard Medical School, Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States
| | - Gregory W. Randolph
- Harvard Medical School, Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States
- Massachusetts General Hospital, Harvard Medical School, Department of Surgery, Boston, Massachusetts, United States
| | - Wen-Xin Zhao
- Fujian Medical University Union Hospital, Department of Thyroid Surgery, Fuzhou, China
- Fujian Clinical Research Center for Precision Management of Thyroid Cancers, Fuzhou, China
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Sobutay E, Cakit H, Terzioglu T. Assessing Parathyroid Gland Viability and Predicting Postoperative Hypoparathyroidism in Thyroid Surgery: The Utility of Indocyanine Green Angiography. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:466-472. [PMID: 38268654 PMCID: PMC10805044 DOI: 10.14744/semb.2023.06691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 01/26/2024]
Abstract
Objectives Postoperative hypoparathyroidism is a common complication following thyroidectomy, with the potential for significant morbidity and cost. While various techniques have been proposed for intraoperative parathyroid gland (PG) identification and preservation, indocyanine green (ICG) angiography has emerged as a promising method. In this retrospective study, patients who underwent total thyroidectomy with or without central neck dissection were evaluated for the utility of ICG angiography in identifying PGs and the correlation of ICG scores with postoperative parathyroid function. Methods ICG angiography was performed using a standardized protocol, and the degree of PG vascularization was assessed visually. A scoring system was employed based on ICG uptake intensity in PGs, as described in the literature. Pearson's correlation test examined the relationship between the total ICG score and percentage parathyroid hormone (PTH) gradient, postoperative calcium, and PTH levels. In addition, patients with at least one well-vascularized PG were also evaluated. Results Twenty-two patients were included in the study. Significant positive correlations were found between the total ICG score and postoperative PTH levels (r=0.549, p=0.008), and a negative correlation with the percentage of PTH gradient (r=-0.504, p=0.01). However, six patients with well-vascularized PGs on ICG angiography still developed postoperative hypoparathyroidism. Conclusion ICG angiography offers a potential tool for evaluating PG vascularization during thyroidectomy and predicting the risk of postoperative hypoparathyroidism. However, its application should be used judiciously, and the technique should be improved for PG preservation. Further studies are warranted to better understand its benefits and limitations in thyroid surgery.
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Affiliation(s)
- Erman Sobutay
- Department of General Surgery, Koc Foundation American Hospital, Istanbul, Türkiye
| | - Hakan Cakit
- Department of General Surgery, Koc Foundation American Hospital, Istanbul, Türkiye
| | - Tarik Terzioglu
- Department of General Surgery, Koc Foundation American Hospital, Istanbul, Türkiye
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Cho JG, Choi SY, Oh KH, Baek SK, Kwon SY, Jung KY, Woo JS. A new histopathological location of parathyroid gland with high possibility of unintended parathyroidectomy. Gland Surg 2023; 12:1714-1721. [PMID: 38229841 PMCID: PMC10788564 DOI: 10.21037/gs-23-282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/26/2023] [Indexed: 01/18/2024]
Abstract
Background Unintended parathyroidectomy occasionally happens despite meticulous capsular dissection and the histopathological location of removed parathyroid glands were traditionally classified as extracapsular, subcapsular, and intrathyroidal location. This study aimed to investigate the new histopathological location of parathyroid gland with high possibility of unintended parathyroidectomy that was difficult to be found with naked eye despite capsular dissection. Methods This study investigated unintended parathyroidectomy that occurred in 743 patients who received thyroid surgery by reviewing pathology reports and slides. The histopathological location of unintentionally removed parathyroid glands was classified as intracapsule and extracapsule, and the intracapsular glands were further classified as completely buried in the thyroid parenchyme, partially buried, and subcapsular locations. Results The incidence of unintended parathyroidectomy was 12.8%. Among the 103 unintentionally removed parathyroid glands, 74 (71.8%) were found intracapsular and 29 were extracapsular. Among the intracapsular glands, 57 (55.4%) parathyroid glands were found in difficult locations such as completely buried (40.8%) and partially buried (14.6%). Conclusions The partially buried parathyroid gland can act as a risk factor for unintended parathyroidectomy comparable to intrathyroidal parathyroid gland despite the surgeon's best effort with meticulous capsular dissection. However, continued advances in visualizing technique such as autofluorescence imaging may lower the chance of incidentally removed partially buried parathyroid glands in the future.
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Affiliation(s)
- Jae-Gu Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Seok-Youl Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Kyung Ho Oh
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Seung-Kuk Baek
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Anam Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Soon-Young Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Kwang-Yoon Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Anam Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Jeong-Soo Woo
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
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Rao SS, Rao H, Moinuddin Z, Rozario AP, Augustine T. Preservation of parathyroid glands during thyroid and neck surgery. Front Endocrinol (Lausanne) 2023; 14:1173950. [PMID: 37324265 PMCID: PMC10266226 DOI: 10.3389/fendo.2023.1173950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/13/2023] [Indexed: 06/17/2023] Open
Abstract
The parathyroid glands are situated in close proximity to the thyroid gland. They have an important endocrine function maintaining calcium and phosphate homeostasis in the body by the secretion of parathormone (PTH), which is responsible for this function. The parathyroid glands are commonly damaged during thyroid surgeries. This could lead to transient or permanent hypoparathyroidism in 30% of cases. Preservation of the parathyroid glands, is an important and integral part of thyroidectomy and other surgical interventions in the neck. The main principle underlying this is a thorough understanding of parathyroid anatomy in relation to the thyroid gland and other important structures in the area. There can also be significant variation in the anatomical location of the glands. Various techniques and methods have been described for parathyroid preservation. They include intraoperative identification utilizing indocyanine green (ICG) fluorescence, carbon nanoparticles, loupes, and microscopes. The techniques of surgery (meticulous capsular dissection), expertise, central compartment neck dissection, preoperative vitamin D deficiency, extent and type of thyroidectomy are the risk factors associated with damaged thyroids, inadvertent parathyroidectomy and subsequent hypoparathyroidism. Parathyroid Autotransplantation is a treatment option for inadvertent parathyroidectomy. Ultimately, the best way to assure normal parathyroid function is to preserve them in situ intraoperatively undamaged.
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Affiliation(s)
- Smitha S. Rao
- Department of Endocrine and Breast Surgery, Oncology, K.S. Hegde Medical Academy, Nitte University, Mangalore, India
| | - Himagirish Rao
- Department of Endocrine and General Surgery, St. John's National Academy of Health Sciences, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Zia Moinuddin
- Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Anthony P. Rozario
- Department of Endocrine and General Surgery, St. John's National Academy of Health Sciences, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Titus Augustine
- Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Yuan Y, Li X, Bao X, Huangfu M, Zhang H. The magic mirror: a novel intraoperative monitoring method for parathyroid glands. Front Endocrinol (Lausanne) 2023; 14:1160902. [PMID: 37284221 PMCID: PMC10239973 DOI: 10.3389/fendo.2023.1160902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/01/2023] [Indexed: 06/08/2023] Open
Abstract
The accurate detection of parathyroid glands (PGs) during surgery is of great significance in thyroidectomy and parathyroidectomy, which protects the function of normal PGs to prevent postoperative hypoparathyroidism and the thorough removal of parathyroid lesions. Existing conventional imaging techniques have certain limitations in the real-time exploration of PGs. In recent years, a new, real-time, and non-invasive imaging system known as the near-infrared autofluorescence (NIRAF) imaging system has been developed to detect PGs. Several studies have confirmed that this system has a high parathyroid recognition rate and can reduce the occurrence of transient hypoparathyroidism after surgery. The NIRAF imaging system, like a magic mirror, can monitor the PGs during surgery in real time, thus providing great support for surgeries. In addition, the NIRAF imaging system can evaluate the blood supply of PGs by utilizing indocyanine green (ICG) to guide surgical strategies. The NIRAF imaging system and ICG complement each other to protect normal parathyroid function and reduce postoperative complications. This article reviews the effectiveness of the NIRAF imaging system in thyroidectomies and parathyroidectomies and briefly discusses some existing problems and prospects for the future.
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Azargoshasb S, Boekestijn I, Roestenberg M, KleinJan GH, van der Hage JA, van der Poel HG, Rietbergen DDD, van Oosterom MN, van Leeuwen FWB. Quantifying the Impact of Signal-to-background Ratios on Surgical Discrimination of Fluorescent Lesions. Mol Imaging Biol 2023; 25:180-189. [PMID: 35711014 PMCID: PMC9971139 DOI: 10.1007/s11307-022-01736-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/28/2022] [Accepted: 04/21/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Surgical fluorescence guidance has gained popularity in various settings, e.g., minimally invasive robot-assisted laparoscopic surgery. In pursuit of novel receptor-targeted tracers, the field of fluorescence-guided surgery is currently moving toward increasingly lower signal intensities. This highlights the importance of understanding the impact of low fluorescence intensities on clinical decision making. This study uses kinematics to investigate the impact of signal-to-background ratios (SBR) on surgical performance. METHODS Using a custom grid exercise containing hidden fluorescent targets, a da Vinci Xi robot with Firefly fluorescence endoscope and ProGrasp and Maryland forceps instruments, we studied how the participants' (N = 16) actions were influenced by the fluorescent SBR. To monitor the surgeon's actions, the surgical instrument tip was tracked using a custom video-based tracking framework. The digitized instrument tracks were then subjected to multi-parametric kinematic analysis, allowing for the isolation of various metrics (e.g., velocity, jerkiness, tortuosity). These were incorporated in scores for dexterity (Dx), decision making (DM), overall performance (PS) and proficiency. All were related to the SBR values. RESULTS Multi-parametric analysis showed that task completion time, time spent in fluorescence-imaging mode and total pathlength are metrics that are directly related to the SBR. Below SBR 1.5, these values substantially increased, and handling errors became more frequent. The difference in Dx and DM between the targets that gave SBR < 1.50 and SBR > 1.50, indicates that the latter group generally yields a 2.5-fold higher Dx value and a threefold higher DM value. As these values provide the basis for the PS score, proficiency could only be achieved at SBR > 1.55. CONCLUSION By tracking the surgical instruments we were able to, for the first time, quantitatively and objectively assess how the instrument positioning is impacted by fluorescent SBR. Our findings suggest that in ideal situations a minimum SBR of 1.5 is required to discriminate fluorescent lesions, a substantially lower value than the SBR 2 often reported in literature.
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Affiliation(s)
- Samaneh Azargoshasb
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Imke Boekestijn
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Meta Roestenberg
- Department of Parasitology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Gijs H KleinJan
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jos A van der Hage
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Daphne D D Rietbergen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Matthias N van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands. .,Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
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Yan S, Lin L, Zhao W, Wang B, Zhang L, Cai S. An improved method of searching inferior parathyroid gland for the patients with papillary thyroid carcinoma based on a retrospective study. Front Surg 2023; 9:955855. [PMID: 36684190 PMCID: PMC9852712 DOI: 10.3389/fsurg.2022.955855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/21/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Many surgeons knew the importance of parathyroid gland (PG) in the thyroid surgery, but it was even more difficult to be protected. This study aimed at evaluating the effectiveness of the improved method of searching inferior parathyroid gland (IPG). Methods 213 patients were enrolled and divided into test and control groups according to different methods of searching IPG in the surgery. Consequently, we compared the surgical outcome parameters between the two groups, including the operative time, numbers of PG identifying (PG protection in situ, PG auto-transplantation, and PG accidental removal), numbers of the total lymph node (LN) and metastatic LN, parathyroid hormone (PTH), transient hypoparathyroidism, transient recurrent laryngeal nerve palsy, and postoperative bleeding. Results We identified 194 (194/196, 98.98%) and 215 (215/230, 93.48%) PGs in the test group and control group, respectively, and there was a significant difference (P = 0.005), and this result was due to IPG identification differences (96/98, 97.96% vs. 100/115, 86.96%, P = 0.004). Meanwhile, there was a lower ratio of IPG auto-transplantation in the test group compared with that in the control group (46.94% vs. 64.35%, P = 0.013). Serum PTH one day after the operation was 3.65 ± 1.86 vs. 2.96 ± 1.64 (P = 0.043) but with no difference at 6 months. There were no differences in metastatic LN and recurrent laryngeal nerve palsy between two groups. Conclusion The improved method of searching IPG was simple, efficient, and safe, which was easy to be implemented for searching IPG and protecting it well.
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Affiliation(s)
- Shouyi Yan
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Lanqin Lin
- The Department of Anesthesia and Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wenxin Zhao
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China,Correspondence: Wenxin Zhao
| | - Bo Wang
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liyong Zhang
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shaojun Cai
- Fujian Medical University, Fuzhou, China,Department of Thyroid Surgery, Fujian Medical University Union Hospital, Fuzhou, China,The Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Minimal Invasive Center, Fujian Medical University Union Hospital, Fuzhou, China
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Chen R, Zhang K, Liu J, Guo L, Liu K, Geng C. Preoperative ultrasound identification and localization of the inferior parathyroid glands in thyroid surgery. Front Endocrinol (Lausanne) 2023; 14:1094379. [PMID: 36923217 PMCID: PMC10009105 DOI: 10.3389/fendo.2023.1094379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/08/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION The parathyroid glands are important endocrine glands for maintaining calcium and phosphorus metabolism, and they are vulnerable to accidental injuries during thyroid cancer surgery. The aim of this retrospective study was to investigate the application of high-frequency ultrasound imaging for preoperative anatomical localization of the parathyroid glands in patients with thyroid cancer and to analyze the protective effect of this technique on the parathyroid glands and its effect on reducing postoperative complications. MATERIALS AND METHODS A total of 165 patients who were operated for thyroid cancer in our hospital were included. The patients were assigned into two groups according to the time period of surgery: Control group, May 2018 to February 2021 (before the application of ultrasound localization of parathyroid in our hospital); PUS group, March 2021 to May 2022. In PUS group, preoperative ultrasound was used to determine the size and location of bilateral inferior parathyroid glands to help surgeons identify and protect the parathyroid glands during operation. We compared the preoperative ultrasound results with the intraoperative observations. Preoperative and first day postoperative serum calcium and PTH were measured in both groups. RESULTS Our preoperative parathyroid ultrasound identification technique has more than 90% accuracy (true positive rate) to confirm the location of parathyroid gland compared to intraoperative observations. Postoperative biochemical results showed a better Ca2+ [2.12(0.17) vs. 2.05(0.31), P=0.03] and PTH [27.48(14.88) vs. 23.27(16.58), P=0.005] levels at first day post-operation in PUS group compared to control group. We also found a reduced risk of at least one type of hypoparathyroidism after surgery in control group:26 cases (31.0%) vs. 41 cases (50.6%), p=0.016. CONCLUSION Ultrasound localization of the parathyroid glands can help in the localization, identification and in situ preservation of the parathyroid glands during thyroidectomy. It can effectively reduce the risk of hypoparathyroidism after thyroid surgery.
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Affiliation(s)
- Ruyue Chen
- Department of Breast and Thyroid Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Kaining Zhang
- Department of Ultrasonography, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Ju Liu
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Ling Guo
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Kailin Liu
- Department of Breast and Thyroid Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Chong Geng
- Department of Breast and Thyroid Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- *Correspondence: Chong Geng,
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9
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Advancements in Thyroidectomy: A Mini Review. ENDOCRINES 2022. [DOI: 10.3390/endocrines3040065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Demand for minimally invasive surgery has driven the development of new gadgets and surgical techniques. Yet, questions about safety and skeptical views on new technology have prevented proliferation of new modes of surgery. This skepticism is perhaps due to unfamiliarity of new fields. Likewise, there are currently various remote-access techniques available for thyroid surgeons that only few regions in the world have adapted. This review will explore the history of minimally invasive techniques in thyroid surgery and introduce new technology to be implemented.
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Tension-free thyroidectomy (TFT): initial report. Updates Surg 2022; 74:1953-1960. [PMID: 35913529 DOI: 10.1007/s13304-022-01338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/15/2022] [Indexed: 10/16/2022]
Abstract
The safety of thyroid surgery in terms of recurrent laryngeal nerve palsy and hypoparathyroidism has increased over the last decade. In this study, we present a new method of tension-free thyroidectomy (TFT), which could be used to further decrease the complication rate after a thyroidectomy. The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of the isthmus and successive complete dissection of Berry's ligament. In total, 92 patients (127 nerves at risk) underwent "tension-free thyroidectomy" (TFT) between August and November 2021. All the procedures were performed by a single surgeon at Saint Petersburg State University Hospital. There were 74 females and 18 male patients (ratio 4.1:1) with a mean age of 46.9 (range from 17 to 74). A lobectomy was carried out in 57 (62%) patients and a total thyroidectomy in 35 (38%). In 27 cases, patients additionally underwent central and/or lateral neck dissection. Indications for surgery were papillary carcinoma (N = 34), medullary cancer (N = 2), follicular neoplasia (N = 43), Grave's disease (N = 9), multinodular toxic goiter (N = 3), and multinodular nontoxic goiter (N = 1). Mean thyroid volume was 24.6 ml (ranged 12-70 ml). Intraoperative neuromonitoring was used in all the cases (5 mA). Translaryngeal ultrasound (TLUS) or direct laryngoscopy were routinely used prior and after surgery to evaluate vocal cords mobility. Calcium and parathormone levels were measured in patients after thyroidectomy on the first, 14th and 30th postoperative days. No recurrent laryngeal nerve palsy was observed. One patient exhibited hypoparathyroidism which was resolved in 2 weeks using substitution therapy with calcium and alfacalcidol. The mean operating time for lobectomy was 54 ± 14 min (range: 30-95 min) and for total thyroidectomy 99 ± 28 min (range: 55-158 min). There was no conversion to the conventional lateral-to-medial approach. TFT can be considered a safe and feasible operation. Comparative (randomized studies) with conventional dissection technique should be performed to investigate the hypothesis that this approach can provide a lower complication rate.
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Pastoricchio M, Bernardi S, Bortul M, de Manzini N, Dobrinja C. Autofluorescence of parathyroid glands during endocrine surgery with minimally invasive technique. J Endocrinol Invest 2022; 45:1393-1403. [PMID: 35262861 DOI: 10.1007/s40618-022-01774-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Accidental injury to the parathyroid glands (PTGs) is common during thyroid and parathyroid surgery. To overcome the limitation of naked eye in identifying the PTGs, intraoperative autofluorescence imaging has been embraced by an increasing number of surgeons. The aim of our study was to describe the technique and assess its utility in clinical practice. METHODS Near-infrared (NIR) autofluorescence imaging was carried out during open parathyroid and thyroid surgery in 25 patients (NIR group), while other 26 patients underwent traditional PTG detection based on naked eye alone (NO-NIR group). Primary variables assessed for correlation between traditional approach and autofluorescence were number of PTGs identified and incidence of postoperative hypoparathyroidism (hypoPT). RESULTS 81.9% of PTGs were detected by means of fluorescence imaging and 74.5% with visual inspection alone, with an average of 2.72 PTGs visualized per patient using NIR imaging versus approximately 2.4 per patient using naked eye (p = 0.38). Considering only the more complex total thyroidectomies (TTs), the difference was almost statistically significant (p = 0.06). Although not statistically significant, the observed postoperative hypoPT rate was lower in the NIR group. CONCLUSION Despite the limitations and technical aspects still to be investigated, fluorescence seems to reduce this complication rate by improving the intraoperative detection of the PTGs.
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Affiliation(s)
- M Pastoricchio
- Division of General Surgery, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Gorizia, Italy
| | - S Bernardi
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Cattinara Teaching Hospital UCO Medicina Clinica, 34100, Trieste, Italy
| | - M Bortul
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy
| | - N de Manzini
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy
| | - C Dobrinja
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy.
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12
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Sleptsov IV, Chernikov RA, Sablin IV, Pushkaruk AA, Timofeeva NI. Tension-free thyroidectomy — results of the initial 77 operations. ENDOCRINE SURGERY 2022. [DOI: 10.14341/serg12718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND: Surgeons from all over the world make considerable efforts to reduce thyroid intraoperative complications such as recurrent laryngeal nerves trauma and parathyroid vascular supply damage.AIM: The aim of the study was improving thyroidectomy technique to reduce the rate of postoperative complications.MATERIALS AND METHODS: Inclusion criteria were primary thyroid operation in cases of papillary or medullary cancer, follicular tumours (Bethesda IV) and Grave’s disease. Thyroid volume ranged from 12–70 ml. Tension-free technique of thyroidectomy (TFT) was suggested by the authors of this study. Key points of TFT are the following: the first step is the complete dissection of Berry ligament fibers and terminal branches of lower thyroid arteries and vein. There is only lateral traction while medial traction is not applied at all. Mobilization of the upper parathyroid gland is performed at the medial thyroid surface. Thyroid lobe is extracted out of its bed beginning with the lower pole only after complete dissection of Berry’s ligament, vessels and parathyroid glands. The last step of the operation is the dissection of the upper pole thyroid vessels. The mobilized lobe is easily withdrawn downwards, that leads to space increase between external branch of the superior laryngeal nerve and the upper pole of the lobe. Transient and continuous neuromonitoring as well as optical magnification and headlamps were used during operations. Vocal cords function was controlled before and after surgery (on the first day) by means of ultrasound or endoscopic laryngoscopy. Ionized calcium and parathyroid hormone levels were checked in cases of total thyroidectomy group on the day of surgery, on the 1st and 14th postoperative days.RESULTS: 77 consecutive patients were included into the study (continuous sampling of patients). 33 hemithyroidectomies, 13 hemithyroidectomies with central ipsilateral neck dissection, 21 thyroidectomies, 8 thyroidectomies with central neck dissection, 2 thyroidectomies with central and lateral neck dissection were performed by the same surgeon. All the operations were performed by tension-free technique (TFT). There were no cases of loss of signal from the recurrent laryngeal nerves function during all the operations. One case of postoperative transient hypoparathyroidism finished with normalization of parathyroid hormone and calcium levels in 2 weeks after the operation.CONCLUSION: initial experience in TFT allows to recommend this procedure for further practicing and examination.
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Affiliation(s)
- I. V. Sleptsov
- Saint-Petersburg State University Hospital; North-West Center of Endocrinology and Endocrine Surgery
| | - R. A. Chernikov
- Saint-Petersburg State University Hospital; North-West Center of Endocrinology and Endocrine Surgery
| | - I. V. Sablin
- Saint-Petersburg State University Hospital; North-West Center of Endocrinology and Endocrine Surgery
| | - A. A. Pushkaruk
- Saint-Petersburg State University Hospital; North-West Center of Endocrinology and Endocrine Surgery
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13
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Perigli G, Cianchi F, Giudici F, Russo E, Fiorenza G, Petrone L, Sparano C, Staderini F, Badii B, Morandi A. Thyroidectomy for Cancer: The Surgeon and the Parathyroid Glands Sparing. J Clin Med 2021; 10:4323. [PMID: 34640352 PMCID: PMC8509338 DOI: 10.3390/jcm10194323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The diagnosis of thyroid cancer is continuously increasing and consequently the amount of thyroidectomy. Notwithstanding the actual surgical skill, postoperative hypoparathyroidism still represents its most frequent complication. The aims of the present study are to analyze the rate of postoperative hypoparathyroidism after thyroidectomy, performed for cancer by a single first operator, without any technological aid, and to compare the data to those obtained adopting the most recent technological adjuncts developed to reduce the postoperative hypoparathyroidism. METHODS During the period 1997-2020 at the Endocrine Surgery Unit of the Department of Clinical and Experimental Medicine of the University of Florence, 1648 consecutive extracapsular thyroidectomies for cancer (401 with central compartment node dissection) were performed. The percentage of hypoparathyroidism, temporary or permanent, was recorded both in the first period (Group A) and in the second, most recent period (Group B). Total thyroidectomies were compared either with those with central compartment dissection and lobectomies. Minimally invasive procedures (MIT, MIVAT, some transoral) were also compared with conventional. Fisher's exact and Chi-square tests were used for comparison of categorical variables. p < 0.01 was considered statistically significant. Furthermore, a literature research from PubMed® has been performed, considering the most available tools to better identify parathyroid glands during thyroidectomy, in order to reduce the postoperative hypoparathyroidism. We grouped and analyzed them by technological affinity. RESULTS On the 1648 thyroidectomies enrolled for the study, the histotype was differentiated in 93.93 % of cases, medullary in 4% and poorly differentiated in the remaining 2.06%. Total extracapsular thyroidectomy and lobectomy were performed respectively in 95.45% and 4.55%. We recorded a total of 318 (19.29%) cases of hypocalcemia, with permanent hypoparathyroidism in 11 (0.66%). In regard to the literature, four categories of tools to facilitate the identification of the parathyroids were identified: (a) vital dye; (b) optical devices; (c) autofluorescence of parathyroids; and (d) autofluorescence enhanced by contrast media. Postoperative hypoparathyroidism had a variable range in the different groups. CONCLUSIONS Our data confirm that the incidence of post-surgical hypoparathyroidism is extremely low in the high volume centers. Its potential reduction adopting technological adjuncts is difficult to estimate, and their cost, together with complexity of application, do not allow immediate routine use. The trend towards increasingly unilateral surgery in thyroid carcinoma, as confirmed by our results in case of lobectomy, is expected to really contribute to a further reduction of postsurgical hypoparathyroidism.
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Affiliation(s)
- Giuliano Perigli
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
| | - Fabio Cianchi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
| | - Francesco Giudici
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
| | - Edda Russo
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
| | - Giulia Fiorenza
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
| | - Luisa Petrone
- Department of Biomedical, Experimental and Clinical Sciences Mario Serio, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (L.P.); (C.S.)
| | - Clotilde Sparano
- Department of Biomedical, Experimental and Clinical Sciences Mario Serio, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (L.P.); (C.S.)
| | - Fabio Staderini
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
| | - Benedetta Badii
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
| | - Alessio Morandi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy; (G.P.); (F.C.); (E.R.); (G.F.); (F.S.); (B.B.); (A.M.)
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14
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Predicting risk factors of postoperative hypocalcemia after total thyroidectomy: is safe discharge without supplementation possible? A large cohort study. Langenbecks Arch Surg 2021; 406:2425-2431. [PMID: 34374848 DOI: 10.1007/s00423-021-02237-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE With increasing economic pressures to shorten the length of hospital stay, there has been much recent interest in studying risk factors for the development of postoperative hypocalcemia after total thyroidectomy. The aim of this study was to investigate whether serum calcium and/or PTH levels can predict post-thyroidectomy hypoparathyroidism. METHODS From January to December 2014, 477 consecutive patients undergoing total thyroidectomy were included. Corrected calcemia and PTH were systematically performed on postoperative day 1/(POD1). Symptomatic patients were treated on POD1 or POD2 with calcium and vitamin D. RESULTS Sixty-eight patients (14.25%) were treated for postoperative hypocalcemia. No patients with calcemia ≥ 2.16 mmol/l and PTH ≥ 1.9 pmol/l were supplemented and therefore were safely discharged on POD1 (specificity = 100%). All patients with calcemia ≤ 1.89 mmol/l were treated regardless the PTH values (n = 10) (specificity = 100%). For calcium value between 1.9 and 2.16 mmol/l with a PTH > 4.7 pmol/l, nobody was treated. With a calcemia between 1.9 and 2.16 mmol/l and a PTH > 1.9 pmol/l, 44 patients did not develop any symptom. ROC curve analysis showed that combination of Cac = 2.16 mmol/l and iPTH = 4.7 pmol/l provided a sensitivity of 97.06% and a specificity of 76.53% (p < 0.0001). We therefore propose an algorithm that would allow to 70% of patients could have been discharged on POD1 without risk of hypocalcemia or overtreatment. CONCLUSION Combination of corrected calcemia and PTH on POD1 can efficiently predict hypocalcemia and be integrated into clinical practice for personalizing lengths of hospitalization and appropriate treatment. TRIAL REGISTRATION ClinicalTrials.gov PRS. Unique Identifying number or registration ID: NCT04372225.
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15
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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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16
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Wiseman SM, Saleh N, Tootooni A, Eshraghi P, Jama R, Saleh S. Parathyroid identification during thyroid and parathyroid operations: A pilot study evaluating a novel low cost autofluorescence based device. Am J Surg 2021; 221:1150-1158. [PMID: 33745690 DOI: 10.1016/j.amjsurg.2021.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/26/2021] [Accepted: 03/02/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to develop a low-cost prototype near-infrared fluorescence device that enables contrast-free, real time, high-resolution intraoperative visualization of normal and pathological parathyroid glands (PGs) by imaging their autofluorescence (AF). METHODS A novel near-infrared parathyroid AF (NIR-PAF) imaging device with visible laser PG targeting was developed. The device was evaluated during parathyroid and thyroid operations in a pilot clinical study. RESULTS Overall, of the 6 parathyroidectomies carried out in the study population a parathyroid adenoma was found to exhibit AF ex vivo in 6/6 (100%) of cases, and in vivo in 3/3 (100%) of these cases. Two of 4 thyroidectomies were evaluated in vivo and all PGs (6 PGs total) were identified by the NIR-PAF device. The NIRPAF device cost less than $1200 Canadian to build. CONCLUSION The inexpensive NIR-PAF device that we developed can successfully intraoperatively identify both normal and pathological PGs.
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Affiliation(s)
- Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada.
| | - Nima Saleh
- Department of Electrical and Computer Engineering, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Amir Tootooni
- Department of Electrical and Computer Engineering, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Parisa Eshraghi
- Department of Electrical and Computer Engineering, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Randy Jama
- Department of Electrical and Computer Engineering, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Sina Saleh
- Department of Electrical and Computer Engineering, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada.
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17
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Tabei I, Fuke A, Fushimi A, Takeyama H. Determination of the Optimum Excitation Wavelength for the Parathyroid Gland Using a Near-Infrared Camera. Front Surg 2021; 7:619859. [PMID: 33553239 PMCID: PMC7859514 DOI: 10.3389/fsurg.2020.619859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/23/2020] [Indexed: 11/13/2022] Open
Abstract
When performing thyroid/parathyroid surgery, difficulty detecting the parathyroid gland is a common experience because it is frequently mistaken with surrounding structures, including the thyroid gland, lymph nodes, and fat. To obtain successful surgical results, the auto fluorescent property of the parathyroid gland occurring at 820-830 nm has been used. Intraoperative visualization and detection by fluorescence enable protection of the gland from damage and unintended removal. Use of a near-infrared (NIR) camera has been proposed to indicate the parathyroid gland, but the devices and success rates have varied. This study aimed to define optimum excitation wavelength (EWL) by measuring the EWL of the parathyroid gland for its autofluorescence. Glands were exposed to EWL at 10-nm intervals from 670-790 nm with a light-emitting diode monochromator; autofluorescence intensity was recorded with a conventional NIR video camera. Autofluorescence intensity curves of three normal parathyroid glands were depicted; the optimum EWL was measured as 760-770 nm. Also, the illumination of the surrounding structures were compared at the optimum EWL. The auto fluorescent intensity of the parathyroid gland was 2-fold greater than for surrounding structures. This difference in fluorescence intensity should enable distinction of the parathyroid gland from surrounding structures. The clarification of the optimum EWL can guide refinements of the NIR camera for better surgical outcomes by improving detection of the parathyroid glands. Also, an understanding of optimum EWL should lead to developments for microscopic devices to unravel the still unknown mechanisms of the intrinsic autofluorescence of the parathyroid gland.
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Affiliation(s)
- Isao Tabei
- Department of Surgery, Daisan Hospital, The Jikei University School of Medicine, Tokyo, Japan.,Breast, Thyroid, and Endocrine Division, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Azusa Fuke
- Department of Surgery, Daisan Hospital, The Jikei University School of Medicine, Tokyo, Japan.,Breast, Thyroid, and Endocrine Division, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Astushi Fushimi
- Breast, Thyroid, and Endocrine Division, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroshi Takeyama
- Breast, Thyroid, and Endocrine Division, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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18
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Van Slycke S, Van Den Heede K, Brusselaers N, Vermeersch H. Feasibility of Autofluorescence for Parathyroid Glands During Thyroid Surgery and the Risk of Hypocalcemia: First Results in Belgium and Review of the Literature. Surg Innov 2020; 28:409-418. [PMID: 33372584 DOI: 10.1177/1553350620980263] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Post-operative hypocalcemia remains the most frequent complication after total thyroidectomy. Recently, autofluorescence imaging was introduced to detect parathyroid glands early during dissection. Aim. We aimed to check the feasibility of autofluorescence regarding the number of parathyroid glands visualised and the risk of post-operative hypocalcemia. Methods. In a prospectively gathered cohort of patients undergoing thyroid surgery, we describe the risk of hypocalcemia in relation to the number of parathyroid glands visualised during surgery (and the risk reported in the scientific literature) and the feasibility to obtain an autofluorescence of the parathyroid glands. Results. From 2010 to 2019, 1083 patients were referred for total thyroidectomy in our tertiary referral centre for endocrine surgery, of which, 40 consecutive cases were operated using autofluorescence. Among the autofluorescence group, 14 (35.0%) had all 4 parathyroid glands visualised, compared to 147 (14.1%) in the other patients, without differences in the number of parathyroid glands reimplanted. No permanent hypocalcemia occurred in the autofluorescence group and 17.5% temporary hypoparathyroidism, compared to 3.1% and 31.9% among the other patients, and 4% (95% confidence interval [CI] 3-5%) and 19% (95% CI 15-24%) in the literature. Conclusion. Autofluorescence imaging provides reliable real-time visualisation at any point during thyroid surgery and helps to identify the parathyroid glands before detection with the naked eye. To date, it cannot be used as a standard technique and does not replace meticulous dissection. To become a useful adjunct in peroperative parathyroid management, large multicentre studies need to establish a potential clinical benefit of this novel technique.
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Affiliation(s)
- Sam Van Slycke
- Department of General and Endocrine Surgery, 74840Onze-Lieve-Vrouw (OLV) Hospital Aalst, Aalst, Belgium.,Department of Head and Skin, RinggoldID:60200University Hospital Ghent, Ghent, Belgium.,Department of General Surgery, 81800AZ Damiaan, Gouwelozestraat, Ostend, Belgium
| | - Klaas Van Den Heede
- Department of General and Endocrine Surgery, 74840Onze-Lieve-Vrouw (OLV) Hospital Aalst, Aalst, Belgium.,Department of Endocrine Surgery, 129363Hammersmith Hospital, London, UK
| | - Nele Brusselaers
- Department of Head and Skin, RinggoldID:60200University Hospital Ghent, Ghent, Belgium.,Centre for Translational Microbiome Research Department of Microbiology, Tumour and Cell Biology, 27106Karolinska Institute, Stockholm, Sweden
| | - Hubert Vermeersch
- Department of Head and Skin, RinggoldID:60200University Hospital Ghent, Ghent, Belgium.,Plastic and Reconstructive Surgery, Department of Human Structure and Repair, 60200University Hospital Ghent, Ghent, Belgium
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19
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Maurer E, Vorländer C, Zielke A, Dotzenrath C, von Frankenberg M, Köhler H, Lorenz K, Weber T, Jähne J, Hammer A, Böttcher KA, Schwarz K, Klinger C, Buhr HJ, Bartsch DK. Short-Term Outcomes of Surgery for Graves' Disease in Germany. J Clin Med 2020; 9:jcm9124014. [PMID: 33322553 PMCID: PMC7763951 DOI: 10.3390/jcm9124014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/29/2020] [Accepted: 12/07/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Surgical treatment of Graves' disease (GD) has a potentially increased incidence of postoperative hypoparathyroidism, recurrent laryngeal nerve palsy (RLNP) and bleeding. The aim of this study was to evaluate the current extent of surgery for the treatment of GD and its safety as a short-term outcome. METHODS Patients who underwent thyroid resection for GD were identified from the prospective StuDoQ/Thyroid registry. Patient data were retrospectively analyzed regarding demographics, surgical procedures and perioperative outcomes. Statistics were performed with Student's t-test or Fisher's exact test and multivariate Cox regression analysis. The level of statistical significance was set at p < 0.05. RESULTS A total of 1808 patients with GD with a median age of 44 (range 14-85) years were enrolled in a 25-month period by 78 departments, of which 35.7% (n = 645) had an endocrine orbitopathy and 0.1% (n = 6) had thyrotoxic crisis. Conventional open surgery was used in 98.6% of cases and minimally invasive or remote-access approaches were used in 1.4%. Total thyroidectomy was performed in 93.4% of cases (n = 1688). Intraoperative neuromonitoring (IONM) was used in 98.9% (n = 1789) of procedures. In 98.3% (n = 1777) at least one parathyroid gland was visualized and in 20.7% (n = 375) parathyroids were autografted. The rates of unilateral and bilateral transient RLNP were 3.9% (n = 134/3429 nerves at risk) and 0.1% (n = 4/3429 NAR). The rates of transient RLNP tended to be higher when intermittent IONM was used compared to continuous IONM (4.1% vs. 3.4%, p < 0.059). The rate of transient postoperative hypoparathyroidism was overall 29% (n = 525/1808). Multivariate analysis revealed fewer than 300 thyroid resections and fewer than 15 thyroid resections for GD per year, male sex, BMI > 30, autotransplantation of parathyroid glands and previous bilateral thyroid surgery as independent risk factors for postoperative temporary hypoparathyroidism. Reoperations for bleeding (1.3%) were rare. CONCLUSION Total thyroidectomy with IONM is safe and currently the most common surgical therapy for GD in Germany. Postoperative hypoparathyroidism is the major complication which should be focused on.
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Affiliation(s)
- Elisabeth Maurer
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg Baldingerstrasse, 35043 Marburg, Germany;
- Correspondence:
| | - Christian Vorländer
- Department of Endocrine Surgery, Bürgerhospital Frankfurt/Main, 60318 Frankfurt am Main, Germany;
| | - Andreas Zielke
- Department of Endocrine Surgery, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany;
| | - Cornelia Dotzenrath
- Department of Endocrine Surgery, Helios Universityhospital Wuppertal, 42283 Wuppertal, Germany;
| | | | - Hinrich Köhler
- Department of General Surgery, Herzogin Elisabeth Hospital Braunschweig, 38124 Braunschweig, Germany;
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, University Medical Center Halle, 06120 Halle, Germany;
| | - Theresia Weber
- Department of Endocrine Surgery, Katholisches Klinikum Mainz, 55131 Mainz, Germany;
| | - Joachim Jähne
- Department of General and Visceral Surgery, Diakovere Henriettenstift Hannover, 30171 Hannover, Germany;
| | - Antonia Hammer
- Department of Endocrine Surgery, DKD Helios Clinic Wiesbaden, 65191 Wiesbaden, Germany;
| | - Knut A. Böttcher
- Department of General and Visceral Surgery, Diakonissen Hospital Mannheim, 68163 Mannheim, Germany;
| | - Katharina Schwarz
- Department of Endocrine Surgery, Lukas Hospital GmbH Neuss, 41464 Neuss, Germany;
| | - Carsten Klinger
- German Society of General and Visceral Surgery, 10117 Berlin, Germany; (C.K.); (H.J.B.)
| | - Heinz J. Buhr
- German Society of General and Visceral Surgery, 10117 Berlin, Germany; (C.K.); (H.J.B.)
| | - Detlef K. Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg Baldingerstrasse, 35043 Marburg, Germany;
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20
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Barbieri D, Indelicato P, Vinciguerra A, Di Marco F, Formenti AM, Trimarchi M, Bussi M. Autofluorescence and Indocyanine Green in Thyroid Surgery: A Systematic Review and Meta-Analysis. Laryngoscope 2020; 131:1683-1692. [PMID: 33247620 DOI: 10.1002/lary.29297] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS To estimate the impact of optical techniques on prevention of post-operative hypocalcemia and hypoparathyroidism after total thyroidectomy. STUDY DESIGN Systematic review and meta-analysis. METHODS A literature search was conducted in Pubmed, EMBASE, SCOPUS, and Cochrane databases. The main inclusion criteria for eligible articles for meta-analysis were patients with benign or malignant thyroid pathologies who underwent total thyroidectomy, utilization of optical techniques to support PGs preservation, the availability of calcium and/or PTH levels. The primary outcome was to evaluate the variation of calcium and PTH levels when adopting optical technologies compared to standard naked-eye surgery. RESULTS In total, 13 papers with 1484 procedures were included. Pooled proportion for short- and medium-term hypocalcemia rates were 8% (95% CI, 5%:11%) and 1% (95% CI, 0%:4%) for optical techniques, while for naked-eye surgery were 15% (95% CI, 9%:23%) and 5% (95% CI, 2%:9%), respectively. CONCLUSIONS Optical technologies reduced short and medium term hypocalcemia compared to conventional surgery. LEVEL OF EVIDENCE NA Laryngoscope, 131:1683-1692, 2021.
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Affiliation(s)
- Diego Barbieri
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pietro Indelicato
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Vinciguerra
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Federico Di Marco
- Urological Research Institute (URI), Division of experimental oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Maria Formenti
- Department of Endocrinology, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Trimarchi
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Mario Bussi
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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21
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Karunakaran P, Abraham DT, Devadas G, Ramalingam S, Balu S, Hussain Z. The impact of operative duration and intraoperative fluid dynamics on postoperative hypocalcemia after total thyroidectomy: a prospective non-randomized study. Langenbecks Arch Surg 2020; 406:1211-1221. [PMID: 33174169 DOI: 10.1007/s00423-020-02013-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 10/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative hypocalcemia after total thyroidectomy (TT) still remains common. This prospective observation study examined the role of intraoperative time period (IOP) and intravenous fluids (IVF) in transient and permanent (> 6 months) hypocalcemia post-TT. SUBJECTS AND METHOD Consecutive patients (n = 328; age = median (IQR); 34 (15) years; M:F = 65:263) with benign or malignant thyroid disease undergoing TT were evaluated for IOP, intraoperative IVF, serum corrected calcium, intact parathormone (iPTH), and 25-hydroxyvitamin D (25OHD) levels at baseline, 48 h, and 6 months post-TT. RESULTS The incidence of symptomatic transient and permanent hypocalcemia post-TT was 33.5% and 7.9% respectively. In multivariate logistic regression analysis, the independent risk factors for transient hypocalcemia were IOP (odds ratio: 11.6), 48-h iPTH (4.8), IVF (2.9), hyperthyroidism (2.8), and percent calcium decline (1.07), while 25OHD deficiency increased the risk by 10.5 odds in subset with preoperative hypocalcemia. In receiver operating characteristic analysis, IOP, and IVF strongly predicted transient hypocalcemia with a threshold of 123 min and 1085 mL. Area under the curve, sensitivity, and specificity were 0.883 (95% CI: 0.838-0.928), 88.1%, and 74.4% and 0.883 (0.840-0.926; each P = 0.001), 84.4%, and 74.4% respectively. Serum 48-h calcium < 7.8 mg/dL was the only reliable predictor of permanent hypocalcemia. CONCLUSION Operative duration > 123 min and IVF > 1085 mL increased the risk of transient hypocalcemia post-TT manyfold but not permanent hypocalcemia. Routine intraoperative identification, preservation of viable in situ parathyroid glands, and laryngeal nerves increased IOP and rates of transient hypocalcemia but improved long-term outcome.
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Affiliation(s)
- Poongkodi Karunakaran
- The Tamilnadu Dr MGR Medical University, Chennai, 600032, India. .,Endocrine Surgery Unit, Government Mohan Kumaramangalam Medical College, Salem, 636030, India. .,Department of Endocrine Surgery, Madras Medical College, Chennai, Tamilnadu, 600003, India.
| | | | - Geetha Devadas
- Institute of Pathology, Madras Medical College, Chennai, 600003, India
| | - Srinivasan Ramalingam
- ICMR-National Institute for Research in Tuberculosis, Chetpet, Chennai, 600031, India
| | - Sudhapresanna Balu
- Department of Biochemistry, Government Stanley Medical College and Hospital, Chennai, 600001, India
| | - Zahir Hussain
- Department of Endocrine Surgery, Madras Medical College, Chennai, Tamilnadu, 600003, India
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22
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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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23
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Moreno MJ, Ling B, Stanimirovic DB. In vivo near-infrared fluorescent optical imaging for CNS drug discovery. Expert Opin Drug Discov 2020; 15:903-915. [PMID: 32396023 DOI: 10.1080/17460441.2020.1759549] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION In vivo imaging technologies have become integral and essential component of drug discovery, development, and clinical assessment for central nervous system (CNS) diseases. Near-infrared (NIR) fluorescence imaging in the range of 650-950 nm is widely used for pre-clinical in vivo imaging studies. The recent expansion of NIR imaging into the shortwave infrared (SWIR, 1000-1700 nm) window enabled improvements in tissue penetration and resolution required for anatomical, dynamic, and molecular neuroimaging with high potential for clinical translation. AREAS COVERED This review focuses on the latest progress in near-infrared (NIR)-fluorescent optical imaging modalities with an emphasis on the SWIR window. Advantages and challenges in developing novel organic and inorganic SWIR emitters, with special attention to their toxicology and pharmacology, are discussed. Examples of their application in preclinical imaging of brain function and pathology provide a platform to assess the potential for their clinical translation. EXPERT OPINION Propelled through concomitant technological advancements in imaging instrumentation, algorithms and new SWIR emitters, SWIR imaging has addressed key barriers to optical imaging modalities used in pre-clinical studies addressing the CNS. Development of biocompatible SWIR emitters and adoption of SWIR into multi-modal imaging modalities promise to rapidly advance optical imaging into translational studies and clinical applications.
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Affiliation(s)
- Maria J Moreno
- Human Health Therapeutics Research Center, National Research Council Canada , Ottawa, ON, Canada
| | - Binbing Ling
- Human Health Therapeutics Research Center, National Research Council Canada , Ottawa, ON, Canada
| | - Danica B Stanimirovic
- Human Health Therapeutics Research Center, National Research Council Canada , Ottawa, ON, Canada
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24
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Jiang J, Shen M, Lu H. Ultrasonic scalpel with knot tying protects parathyroid function for total thyroidectomy with central neck dissection. Gland Surg 2020; 9:192-199. [PMID: 32420242 DOI: 10.21037/gs.2020.01.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Hypoparathyroidism might be due to collateral thermal injury induced by harmonic scalpel (HS) after total thyroidectomy (TT) with central neck dissection (CND). The current study aimed to evaluate whether a clamp and tie (CAT) technique used to preserve parathyroid glands in situ could reduce damage to parathyroid function in HS patients undergoing TT plus unilateral or bilateral CND. Methods Medical records of 537 HS-operated patients with papillary thyroid carcinoma (PTC) undergoing TT plus unilateral or bilateral CND were retrospectively evaluated. Patients were divided into HS and HS-CAT groups based on whether the CAT techniques were used near parathyroid glands. Patients' characteristics such as age, sex, tumour size, operative time, pre- and post-operative levels of parathyroid hormone (PTH) and complications were analysed. Results For patients undergoing TT plus unilateral CND, operative time was significantly shorter (P<0.001), but there were significantly higher incidences of transient hypoparathyroidism (P=0.002) on postoperative day 1 and incidental parathyroidectomy (P=0.036) in the HS group. There was no significant difference in permanent hypoparathyroidism. For patients undergoing TT plus bilateral CND, a significantly shorter operative time and sharper postoperative PTH decline was found in the HS group (P=0.029). However, there were no significant differences regarding incidences of incidental parathyroidectomy, transient or permanent hypoparathyroidism. Conclusions The CAT technique applied near parathyroid glands was a practical surgical application for decreasing the incidence of postoperative transient hypoparathyroidism for TT plus unilateral CND.
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Affiliation(s)
- Jun Jiang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Meiping Shen
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Hui Lu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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25
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Zou X, Shi L, Zhu G, Zhu L, Bao J, Fan J, Hu Y, Zhou B, Lv Z. Fine-needle aspiration with rapid parathyroid hormone assay to identify parathyroid gland in thyroidectomy. Medicine (Baltimore) 2020; 99:e19840. [PMID: 32312007 PMCID: PMC7220132 DOI: 10.1097/md.0000000000019840] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To determine the levels of parathyroid hormone (PTH) in the fluids of various tissues for identification of parathyroid glands during thyroidectomy.Our study comprised 31 patients with thyroid cancer who underwent lobectomy with central compartment dissection at our hospital from October 2014 to February 2015. A total of 186 tissue samples, including 28 from parathyroid glands and 158 from non-parathyroid tissues, were obtained during the operations. Tissue fluids were collected via fine-needle aspiration to measure PTH levels; the tissue was punctured 3 times with a 26-gauge syringe needle and washed with 0.5 mL normal saline. Tissues were also prepared for pathological examination.PTH concentrations were significantly higher in parathyroid tissues than non-parathyroid tissues. None of the patients had irremediable parathyroid dysfunction after surgical resection.Use of fine-needle aspiration for quantification of PTH levels in tissue fluids rapidly, safely, and effectively identifies the parathyroid glands during thyroidectomy.
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Affiliation(s)
- Xian Zou
- Jiangyuan Hospital Affiliated to Jiangsu Institute of Nuclear Medicine
| | - Longshun Shi
- Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu
| | - Guohua Zhu
- Jiangyuan Hospital Affiliated to Jiangsu Institute of Nuclear Medicine
| | - Liguo Zhu
- Jiangyuan Hospital Affiliated to Jiangsu Institute of Nuclear Medicine
| | - Jiandong Bao
- Jiangyuan Hospital Affiliated to Jiangsu Institute of Nuclear Medicine
| | - Jun Fan
- Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu
| | - Yonghong Hu
- The Synergetic Innovation Center for Advanced Materials, State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing
| | - Bin Zhou
- Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu
| | - Zhongwei Lv
- Department of Nuclear Medicine, Shanghai 10th People's Hospital, Tongji University School of Medicine, Shanghai, China
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26
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Use of SPY Elite Fluorescence Imaging in Creation of a Continent Urinary Diversion. Case Rep Urol 2019; 2019:9069841. [PMID: 31886015 PMCID: PMC6925922 DOI: 10.1155/2019/9069841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/03/2019] [Indexed: 01/06/2023] Open
Abstract
The use of SPY Elite Fluorescence Imaging has recently grown popular among multiple surgical specialties, including colorectal, plastic, endocrine, ophthalmologic, and vascular surgery, due to its ability to quickly and accurately assess tissue perfusion and guide intraoperative decision making. To our knowledge, the use of SPY imaging in urologic reconstructive surgery has yet to be reported. We present a case in which SPY imaging was used intraoperatively to assess perfusion of an ileocecal anastomosis and a segment of bowel prior to creation of a continent urinary diversion following radical cystectomy.
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27
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Gálvez-Pastor S, Torregrosa NM, Ríos A, Febrero B, González-Costea R, García-López MA, Balsalobre MD, Pastor-Pérez P, Moreno P, Vázquez-Rojas JL, Rodríguez JM. Prediction of hypocalcemia after total thyroidectomy using indocyanine green angiography of parathyroid glands: A simple quantitative scoring system. Am J Surg 2019; 218:993-999. [DOI: 10.1016/j.amjsurg.2018.12.074] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/21/2018] [Accepted: 12/31/2018] [Indexed: 11/12/2022]
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28
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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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29
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Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach. JAMA Surg 2019; 153:21-27. [PMID: 28877292 DOI: 10.1001/jamasurg.2017.3366] [Citation(s) in RCA: 295] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Natural orifice transluminal endoscopic surgery thyroidectomy is a novel approach to avoid surgical scars. Objective To compare the safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) with those of open thyroidectomy (OT). Design, Setting, and Participants This study retrospectively reviewed all TOETVA and OT operations performed from April 1, 2014, through August 31, 2016, at Police General Hospital, Bangkok, Thailand. All patients who underwent TOETVA and patients who underwent OT were included. Exclusion criteria were (1) previous neck surgery, (2) substernal goiter, (3) lymph node or distance metastasis, and (4) suspicious invasion to the adjacent organs. Propensity score matching was conducted to reduce selective bias. Main Outcomes and Measures Operative time, blood loss, and complications related to thyroid surgery. Results Of the 425 patients who underwent transoral endoscopic thyroidectomy (mean age, 35.3 [12.1] years; age range, 16-81 years; 389 [92.2%] female), 422 successfully were treated with the TOETVA; 3 patients were converted to a conventional operation because of bleeding. Twenty-five patients (5.9%) had transient recurrent laryngeal nerve palsy, and 46 (10.9%) had transient hypoparathyroidism. None had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Three patients (0.7%) had transient mental nerve injury; all cases resolved by 4 months. One patient developed postoperative hematoma treated by OT. Twenty patients (4.7%) had seroma treated by simple aspiration. Operative time was longer for the TOETVA compared with the OT group (100.8 [39.7] vs 79.4 [32.1] minutes, P = 1.61 × 10-10). The mean (SD) visual analog scale score for pain was lower in the TOETVA group (1.1 [1.2] vs 2.8 [1.2], P = 2.52 × 10-38). Estimated mean (SD) blood loss (36.9 [32.4] vs 37.6 [23.1] mL, P = .43) and rate of complications (45 of 216 [20.8%] vs 38 of 216 [17.6%], P = .41) were not significantly different in the TOETVA vs OT group. Conclusions and Relevance The TOETVA was performed as safely as OT, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for select patients.
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Affiliation(s)
- Angkoon Anuwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Khwannara Ketwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Pornpeera Jitpratoom
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Thanyawat Sasanakietkul
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
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Lerchenberger M, Gündogar U, Al Arabi N, Gallwas JKS, Stepp H, Hallfeldt KKJ, Ladurner R. Indocyanine green fluorescence imaging during partial adrenalectomy. Surg Endosc 2019; 34:2050-2055. [PMID: 31342258 DOI: 10.1007/s00464-019-06985-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Indocyanine green (ICG) fluorescence imaging represents an emerging technology that facilitates the assessment of tissue vascularity, tissue distinction, and tumor localization during surgery. The aim of this study was to investigate the potential role of ICG imaging during laparoscopic partial adrenalectomy. METHODS Indocyanine fluorescence imaging was carried out during laparoscopic partial adrenalectomy for bilateral pheochromocytoma and bilateral Cushing's syndrome. A first bolus of 5 mg ICG was applied intravenously upon exposure of the retroperitoneal plane to identify the adrenal borders. The fluorescence was visualized using a Storz® NIR/ICG endoscopic system. As the camera of this system detects NIR light as a blue signal, the well-vascularized adrenal tissue was expected to show a strong fluorescence in the blue color channel in contrast to the surrounding adipose tissue. Following partial adrenalectomy, a second bolus of 5 mg ICG was applied intravenously to evaluate the vascularity of the remaining adrenal tissue. RESULTS We investigated six adrenal glands from three patients undergoing bilateral partial adrenalectomy. The indication for surgery was pheochromocytoma in two patients and Cushing's syndrome with bilateral adenomas in one patient. Regarding left adrenalectomies, ICG imaging was helpful in visualizing the adrenal borders and the adrenal vein. Further, it facilitated the identification of the hypofluorescent pheochromocytoma and to resect the entire tumor. On the right side, due to the more apparent anatomy, ICG imaging did not contribute to the conduct of the operation. Four adrenal remnants showed a strong vascularization and two remnants were only reasonably vascularized. CONCLUSION ICG fluorescence may be helpful in guiding partial adrenalectomy and assessing the vascularity of remaining adrenal tissue.
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Affiliation(s)
- Maximilian Lerchenberger
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336, Munich, Germany
| | - Ufuk Gündogar
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336, Munich, Germany
| | - Norah Al Arabi
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336, Munich, Germany
| | - Julia K S Gallwas
- Department of Obstetrics and Gynecology, Ludwig Maximilians University Munich, Maistr. 11, 80337, Munich, Germany
| | - Herbert Stepp
- Laser-Research Laboratory, LIFE-Center, Ludwig Maximilians University Munich, Grosshadern Medical Campus, Feodor-Lynen-Str. 19, 81377, Munich, Germany
| | - Klaus K J Hallfeldt
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336, Munich, Germany.
| | - Roland Ladurner
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336, Munich, Germany
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31
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Ladurner R, Lerchenberger M, Al Arabi N, Gallwas JKS, Stepp H, Hallfeldt KKJ. Parathyroid Autofluorescence-How Does It Affect Parathyroid and Thyroid Surgery? A 5 Year Experience. Molecules 2019; 24:molecules24142560. [PMID: 31337096 PMCID: PMC6680977 DOI: 10.3390/molecules24142560] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 12/22/2022] Open
Abstract
Injury to parathyroid glands during thyroid and parathyroid surgery is common and postoperative hypoparathyroidism represents a serious complication. Parathyroid glands possess a unique autofluorescence in the near-infrared spectrum which could be used for their identification and protection at an early stage of the operation. In the present study parathyroid autofluorescence was visualized intraoperatively using a standard Storz laparoscopic near-infrared/indocyanine green (NIR/ICG) imaging system with minor modifications to the xenon light source (filtered to emit 690 nm to 790 nm light, less than 1% in the red and green above 470 nm and no blue light). During exposure to NIR light parathyroid tissue was expected to show autofluorescence at 820 nm, captured in the blue channel of the camera. Over a period of 5 years, we investigated 205 parathyroid glands from 117 patients. 179 (87.3%) glands were correctly identified by their autofluorescence. Surrounding structures such as thyroid, lymph nodes, muscle, or adipose tissue did not reveal substantial autofluorescence. We conclude that parathyroid glands can be identified by their unique autofluorescence at an early stage of the operation. This may help to preserve these fragile structures and their vascularization and lower the rate of postoperative hypocalcemia.
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Affiliation(s)
- Roland Ladurner
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany
| | - Maximilian Lerchenberger
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany
| | - Norah Al Arabi
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany
| | - Julia K S Gallwas
- Department of Obstetrics and Gynecology, Ludwig Maximilians University Munich, Maistr. 11, 80337 Munich, Germany
| | - Herbert Stepp
- Laser-Research Laboratory, LIFE-Center, Ludwig Maximilians University Munich, Grosshadern Medical Campus, Feodor-Lynen-Str. 19, 81377 Munich, Germany
- Department of Urology, Ludwig Maximilians University Munich, Grosshadern Medical Campus, Marchioninistrasse 15, 81377 Munich, Germany
| | - Klaus K J Hallfeldt
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany.
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Randomized Controlled Trial Comparing White Light with Near-Infrared Autofluorescence for Parathyroid Gland Identification During Total Thyroidectomy. J Am Coll Surg 2019; 228:744-751. [DOI: 10.1016/j.jamcollsurg.2018.12.044] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 12/21/2018] [Accepted: 12/21/2018] [Indexed: 12/24/2022]
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Jongekkasit I, Jitpratoom P, Sasanakietkul T, Anuwong A. Transoral Endoscopic Thyroidectomy for Thyroid Cancer. Endocrinol Metab Clin North Am 2019; 48:165-180. [PMID: 30717900 DOI: 10.1016/j.ecl.2018.11.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The prevalence of low-risk differentiated thyroid cancer (DTC) is dramatically increasing because of superior diagnostic imaging technologies. Remote-access endoscopic thyroidectomy is becoming more popular for the lack of a noticeable neck scar. Transoral endoscopic thyroidectomy, vestibular approach (TOETVA) is the only technique that could be called a true scarless surgery; however, there is a scarcity of long-term studies about its safety and feasibility. Because thyroid cancer is a slow-growing lesion, with adequate follow-up and surveillance, TOETVA is a surgical procedure for the management of low-risk DTC without any difference of surgical and oncological outcome.
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Affiliation(s)
- Isariya Jongekkasit
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, 492/1, Rama 1 Road, Pathumwan, Bangkok 10330, Thailand
| | - Pornpeera Jitpratoom
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, 492/1, Rama 1 Road, Pathumwan, Bangkok 10330, Thailand
| | - Thanyawat Sasanakietkul
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, 492/1, Rama 1 Road, Pathumwan, Bangkok 10330, Thailand
| | - Angkoon Anuwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, 492/1, Rama 1 Road, Pathumwan, Bangkok 10330, Thailand.
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Fanaropoulou NM, Chorti A, Markakis M, Papaioannou M, Michalopoulos A, Papavramidis T. The use of Indocyanine green in endocrine surgery of the neck: A systematic review. Medicine (Baltimore) 2019; 98:e14765. [PMID: 30855479 PMCID: PMC6417629 DOI: 10.1097/md.0000000000014765] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The insufficient reliability of preoperative imaging technology and limited convenience of intraoperative visualizing techniques have been associated with difficulty in surgical navigation in neck endocrine surgery. Indocyanine green (ICG) fluorescence imaging has stood out as the real-time intraoperative guide amidst research for novel modalities, with an emerging use in endocrine surgery. METHODS We performed a systematic review of the PubMed, Scopus and Embase databases, to identify published studies on parathyroid and thyroid operations employing ICG. Well-described articles were selected according to 7 criteria and analyzed per operation type and organ structure. RESULTS Twenty-one articles matched our selection criteria. Dosage, equipment, and techniques are well-described in literature. ICG was found to significantly enhance the surgical experience and outcomes. Occasional discrepancy among studies was attributed to the lack of standard quantification of values and divergence of study designs. CONCLUSION The most successful applications of ICG are:Future research is needed for standard quantification of fluorescence intensity and objective comparisons.
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Affiliation(s)
- Nina Maria Fanaropoulou
- 1st Propedeutic Department of Surgery, AHEPA University Hospital, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Angeliki Chorti
- 1st Propedeutic Department of Surgery, AHEPA University Hospital, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Markos Markakis
- Department of Electrical Engineering, Princeton University, Princeton, NJ, USA
| | - Maria Papaioannou
- Laboratory of Biological Chemistry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Michalopoulos
- 1st Propedeutic Department of Surgery, AHEPA University Hospital, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodosios Papavramidis
- 1st Propedeutic Department of Surgery, AHEPA University Hospital, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Kengelbach-Weigand A, Lotz L, Schmid R, Lang W, Beckmann MW, Hoffmann I, Horch RE, Renner SP, Dittrich R, Boos AM, Hildebrandt T. Intra- and Postoperative Blood Flow Monitoring in a Sheep Model of Uterus Transplantation. In Vivo 2019; 33:325-336. [PMID: 30804109 PMCID: PMC6506297 DOI: 10.21873/invivo.11478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The introduction of the opportunity to transplant a viable uterus into women for fulfilling their desire to have a child has awakened high expectations worldwide. MATERIALS AND METHODS A sheep model was used to evaluate tools for optimizing measurement of blood flow in uterine transplantation. Intraoperatively, blood flow was measured using unidirectional Doppler and indocyanine green (ICG) fluorescence imaging. Postoperatively, an implantable Doppler probe served as a tool for clinical monitoring the patency of anastomosed vessels. RESULTS ICG imaging showed complete vascularization of the uterus before and in short-term evaluation after surgery. The implantable Doppler probe proved to be highly suitable for assessing patency of vessels in a non-invasive way. Results of histology, and real-time polymerase chain reaction demonstrated viability of the transplanted uterus. CONCLUSION Different methods to monitor vasculature patency have proven to be advantageous in supporting both surgeons and researchers in ensuring successful implementation of uterine transplantation.
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Affiliation(s)
- Annika Kengelbach-Weigand
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Laura Lotz
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Rafael Schmid
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Matthias W Beckmann
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Inge Hoffmann
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Stefan P Renner
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Ralf Dittrich
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Anja M Boos
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
| | - Thomas Hildebrandt
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander University of Erlangen (FAU), Erlangen, Germany
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Lerchenberger M, Al Arabi N, Gallwas JKS, Stepp H, Hallfeldt KKJ, Ladurner R. Intraoperative Near-Infrared Autofluorescence and Indocyanine Green Imaging to Identify Parathyroid Glands: A Comparison. Int J Endocrinol 2019; 2019:4687951. [PMID: 31662746 PMCID: PMC6778890 DOI: 10.1155/2019/4687951] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/11/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To investigate the feasibility of near-infrared autofluorescence (AF) and indocyanine green (ICG) fluorescence to identify parathyroid glands intraoperatively. METHODS Fluorescence imaging was carried out during open parathyroid and thyroid surgery. After visual identification, parathyroid glands were exposed to near-infrared (NIR) light with a wavelength between 690 and 770 nm. The camera of the Storz® NIR/ICG endoscopic system used detects NIR light as a blue signal. Therefore, parathyroid AF was expected to be displayed in the blue color channel in contrast to the surrounding tissue. Following AF imaging, a bolus of 5 mg ICG was applied intravenously. ICG fluorescence was detected using the same NIR/ICG imaging system. Well-vascularized parathyroid glands were expected to show a strong fluorescence in contrast to surrounding lymphatic and adipose tissue. RESULTS We investigated 78 parathyroid glands from 50 patients. 64 parathyroid glands (82%) displayed AF showing the typical bluish violet color. 63 parathyroid glands (81%) showed a strong and persistent fluorescence after application of ICG. The sensitivity of identifying a parathyroid gland by AF was 82% (64 true positive and 14 false negative results), while ICG imaging showed a sensitivity of 81% (63 true positive and 15 false negative results). The Fisher exact test revealed no significant difference between both groups at p < 0.05. Neither lymph nodes nor adipose tissue revealed substantial AF or ICG fluorescence. CONCLUSION AF and ICG fluorescence reveal a high degree of sensitivity in identifying parathyroid glands. Further, ICG imaging facilitates the assessment of parathyroid perfusion. However, in the current setting both techniques are not suitable as screening tools to identify parathyroid glands at an early stage of the operation.
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Affiliation(s)
- Max Lerchenberger
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany
| | - Norah Al Arabi
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany
| | - Julia K. S. Gallwas
- Department of Obstetrics and Gynecology, Ludwig Maximilians University Munich, Maistr. 11, 80337 Munich, Germany
| | - Herbert Stepp
- Laser-Research Laboratory, LIFE-Center and Department of Urology, Ludwig Maximilians University Munich, Grosshadern Medical Campus, Feodor-Lynen-Str. 19, 81377 Munich, Germany
| | - Klaus K. J. Hallfeldt
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany
| | - Roland Ladurner
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336 Munich, Germany
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Papayan G, Akopov A. Potential of indocyanine green near-infrared fluorescence imaging in experimental and clinical practice. Photodiagnosis Photodyn Ther 2018; 24:292-299. [DOI: 10.1016/j.pdpdt.2018.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/13/2018] [Accepted: 10/15/2018] [Indexed: 01/08/2023]
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Shirata C, Kawaguchi Y, Kobayashi K, Kobayashi Y, Arita J, Akamatsu N, Kaneko J, Sakamoto Y, Kokudo N, Hasegawa K. Usefulness of indocyanine green-fluorescence imaging for real-time visualization of pancreas neuroendocrine tumor and cystic neoplasm. J Surg Oncol 2018; 118:1012-1020. [DOI: 10.1002/jso.25231] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Chikara Shirata
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Kosuke Kobayashi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Yuta Kobayashi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery; Graduate School of Medicine, The University of Tokyo; Tokyo Japan
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Absorption by water increases fluorescence image contrast of biological tissue in the shortwave infrared. Proc Natl Acad Sci U S A 2018; 115:9080-9085. [PMID: 30150372 DOI: 10.1073/pnas.1803210115] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Recent technology developments have expanded the wavelength window for biological fluorescence imaging into the shortwave infrared. We show here a mechanistic understanding of how drastic changes in fluorescence imaging contrast can arise from slight changes of imaging wavelength in the shortwave infrared. We demonstrate, in 3D tissue phantoms and in vivo in mice, that light absorption by water within biological tissue increases image contrast due to attenuation of background and highly scattered light. Wavelengths of strong tissue absorption have conventionally been avoided in fluorescence imaging to maximize photon penetration depth and photon collection, yet we demonstrate that imaging at the peak absorbance of water (near 1,450 nm) results in the highest image contrast in the shortwave infrared. Furthermore, we show, through microscopy of highly labeled ex vivo biological tissue, that the contrast improvement from water absorption enables resolution of deeper structures, resulting in a higher imaging penetration depth. We then illustrate these findings in a theoretical model. Our results suggest that the wavelength-dependent absorptivity of water is the dominant optical property contributing to image contrast, and is therefore crucial for determining the optimal imaging window in the infrared.
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Cho SS, Zeh R, Pierce JT, Salinas R, Singhal S, Lee JYK. Comparison of Near-Infrared Imaging Camera Systems for Intracranial Tumor Detection. Mol Imaging Biol 2018; 20:213-220. [PMID: 28741043 PMCID: PMC11145178 DOI: 10.1007/s11307-017-1107-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE Distinguishing neoplasm from normal brain parenchyma intraoperatively is critical for the neurosurgeon. 5-Aminolevulinic acid (5-ALA) has been shown to improve gross total resection and progression-free survival but has limited availability in the USA. Near-infrared (NIR) fluorescence has advantages over visible light fluorescence with greater tissue penetration and reduced background fluorescence. In order to prepare for the increasing number of NIR fluorophores that may be used in molecular imaging trials, we chose to compare a state-of-the-art, neurosurgical microscope (System 1) to one of the commercially available NIR visualization platforms (System 2). PROCEDURES Serial dilutions of indocyanine green (ICG) were imaged with both systems in the same environment. Each system's sensitivity and dynamic range for NIR fluorescence were documented and analyzed. In addition, brain tumors from six patients were imaged with both systems and analyzed. RESULTS In vitro, System 2 demonstrated greater ICG sensitivity and detection range (System 1 1.5-251 μg/l versus System 2 0.99-503 μg/l). Similarly, in vivo, System 2 demonstrated signal-to-background ratio (SBR) of 2.6 ± 0.63 before dura opening, 5.0 ± 1.7 after dura opening, and 6.1 ± 1.9 after tumor exposure. In contrast, System 1 could not easily detect ICG fluorescence prior to dura opening with SBR of 1.2 ± 0.15. After the dura was reflected, SBR increased to 1.4 ± 0.19 and upon exposure of the tumor SBR increased to 1.8 ± 0.26. CONCLUSION Dedicated NIR imaging platforms can outperform conventional microscopes in intraoperative NIR detection. Future microscopes with improved NIR detection capabilities could enhance the use of NIR fluorescence to detect neoplasm and improve patient outcome.
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Affiliation(s)
- Steve S Cho
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 235 South Eighth Street, Philadelphia, PA, 19106, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Zeh
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 235 South Eighth Street, Philadelphia, PA, 19106, USA
| | - John T Pierce
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 235 South Eighth Street, Philadelphia, PA, 19106, USA
| | - Ryan Salinas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 235 South Eighth Street, Philadelphia, PA, 19106, USA
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 235 South Eighth Street, Philadelphia, PA, 19106, USA.
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Ladurner R, Al Arabi N, Guendogar U, Hallfeldt K, Stepp H, Gallwas J. Near-infrared autofluorescence imaging to detect parathyroid glands in thyroid surgery. Ann R Coll Surg Engl 2018; 100:33-36. [PMID: 29022781 PMCID: PMC5838663 DOI: 10.1308/rcsann.2017.0102] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2017] [Indexed: 11/22/2022] Open
Abstract
Objective To identify and save parathyroid glands during thyroidectomy by displaying their autofluorescence. Methods Autofluorescence imaging was carried out during thyroidectomy with and without central lymph node dissection. After visual recognition by the surgeon, the parathyroid glands and the surrounding tissue were exposed to near-infrared light with a wavelength of 690-770 nm using a modified Karl Storz near infrared/indocyanine green endoscopic system. Parathyroid tissue was expected to show near infrared autofluorescence at 820 nm, captured in the blue channel of the camera. Results We investigated 41 parathyroid glands from 20 patients; 37 glands were identified correctly based on near-infrared autofluorescence. Neither lymph nodes nor thyroid revealed substantial autofluorescence and nor did adipose tissue. Conclusions Parathyroid tissue is characterised by showing autofluorescence in the near-infrared spectrum. This effect can be used to identify and preserve parathyroid glands during thyroidectomy.
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Affiliation(s)
- R Ladurner
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus , Munich , Germany
| | - N Al Arabi
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus , Munich , Germany
| | - U Guendogar
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus , Munich , Germany
| | - Kkj Hallfeldt
- Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus , Munich , Germany
| | - H Stepp
- Laser-Research Laboratory, LIFE-Center, Ludwig Maximilians University Munich, Grosshadern Medical Campus , Munich , Germany
| | - Jks Gallwas
- Department of Obstetrics and Gynecology, Ludwig Maximilians University Munich, Grosshadern Medical Campus , Munich , Germany
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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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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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Tanda ML, Wu CW, Dionigi G. Recent developments in the follow-up, prevention and management of complications in thyroid surgery. Gland Surg 2017; 6:425-427. [PMID: 29142829 DOI: 10.21037/gs.2017.08.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Maria Laura Tanda
- Division of Endocrinology, Department of Medicine and Surgery, ASST Sette Laghi Ospedale di Circolo e Fondazione Macchi - Polo Universitario, University of Insubria (Varese-Como), Varese, Italy
| | - Che-Wei Wu
- Department of Otolaryngology- Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Sicily, Italy
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Near-Infrared Autofluorescence Image-Guided Parathyroid Gland Mapping in Thyroidectomy. J Am Coll Surg 2017; 226:165-172. [PMID: 29122718 DOI: 10.1016/j.jamcollsurg.2017.10.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 10/16/2017] [Accepted: 10/16/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Studies to date have shown that near-infrared autofluorescence imaging (NIR) can detect the parathyroid gland during thyroidectomy. However, there are no reports that NIR imaging can identify the parathyroid gland when it's covered with fibrofatty tissue before identification by a surgeon's naked eye. In this study, we investigated the feasibility of parathyroid gland mapping to facilitate early identification of the parathyroid gland during thyroidectomy. STUDY DESIGN Seventy parathyroid glands from 38 patients who underwent thyroidectomy for papillary thyroid cancer were included in this prospective study. Near-infrared with infrared illumination (NIR-IR) imaging using a 780-nm light-emitting diode was conducted at the predicted locations of the superior or inferior parathyroid glands. Parathyroid mapping was conducted in 3 stages. Stages P1, P2, and P3 were defined as imaging before identification of the gland by direct visualization, imaging after identification, and imaging in the removed specimen, respectively. RESULTS Sixty-four parathyroid glands (92.8%) could be localized in stage P1 before surgical dissection and exposure of the gland. Five parathyroid glands that were not detected at stage P1 were identified in stages P2 (4 cases, 5.8%) and P3 (1 case, 1.4%). One parathyroid gland was not identified in either the NIR imaging or the pathologic examination. The sensitivity, specificity, and accuracy of parathyroid gland mapping in stages P1, P2, and P3 were all 100%. CONCLUSIONS Parathyroid gland mapping using our NIR-IR imaging technique was feasible, with an excellent accuracy rate. This technique may be helpful for early identification of parathyroid glands during thyroidectomy.
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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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Anuwong A, Kim HY, Dionigi G. Transoral endoscopic thyroidectomy using vestibular approach: updates and evidences. Gland Surg 2017; 6:277-284. [PMID: 28713700 DOI: 10.21037/gs.2017.03.16] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recently, natural orifice transluminal endoscopic surgery (NOTES) has been applied in thyroid surgery with transoral access. The benefit of transoral endoscopic thyroidectomy is the potential for scar-free surgery. However, there are many concerns over some aspects, such as infection, recurrent laryngeal nerve injury, and oncological outcome. In this paper, we have reviewed the development history and the current clinical evidence of this innovative surgery. We conclude that the transoral endoscopic thyroidectomy vestibular approach (TOETVA) is feasible and can be considered no longer an experimental operation.
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Affiliation(s)
- Angkoon Anuwong
- Department of Surgery, Minimally Invasive and Endocrine Surgery Division, Police General Hospital, Bangkok, Thailand
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, Korea
| | - Gianlorenzo Dionigi
- Department of Surgical Sciences and Human Morphology, 1st Division of Surgery, Research Center for Endocrine Surgery, University of Insubria (Como-Varese), Varese, Italy
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Neagoe RM, Cvasciuc IT, Muresan M, Sala DT. INCIDENTAL PARATHYROIDECTOMY DURING THYROID SURGERY - RISK, PREVENTION AND CONTROVERSIES; AN EVIDENCE-BASED REVIEW. ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:467-475. [PMID: 31149218 DOI: 10.4183/aeb.2017.467] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Postoperative hypocalcemia after thyroid surgery has a high prevalence ( 16-55% in different series). Incidental parathyroidectomy (IP) is a less discussed complication of thyroidectomy with consequences not properly defined. The aim of our study was to find incidence, risk factors and how to prevent IP. Methods Extensive search of English literature publications via PubMed was performed and 73 papers from 1980 to 2017 were analysed using the GRADE system/classification, quality of evidence was classified as "strong" when the result is highly unlikely to change existing recommendation and "weak" when opposite. Results Incidence of IP is 3.7-24.9%, while prevalence of permanent hypoparathyroidism is less frequent 6-12%. Direct relation between IP and hypoparathyroidism/hypocalcemia remains controversial. Female patients, ectopic parathyroids, small thyroids, Graves', malignancy, redo surgeries and total thyroidectomy favour IP. Routine visualization of parathyroids, new hemostatic devices, magnifying instruments and fluorescence can prevent incidental removal of parathyroids. Incidence of IP during videoassisted or robotic thyroidectomies was similar to open procedures. High volume, experienced and younger surgeons have lower complication rates (including hypoparathyroidism). Conclusions Incidental parathyroidectomy is more frequent than we might have expected. It should be avoided and parathyroid glands should be kept in situ. Majority of studies are retrospective (low degree of evidence according to previous mentioned GRADE classification) and further meta-analysis or randomized control studies are welcome in order to define the impact of incidental removal of parathyroids on postoperative outcome.
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Affiliation(s)
- R M Neagoe
- University of Medicine and Pharmacy, Second Department of Surgery, Targu Mures, Romania
| | - I T Cvasciuc
- Leeds Teaching Hospitals, Dept. of Endocrine Surgery, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - M Muresan
- University of Medicine and Pharmacy, General Surgery, Targu Mures, Romania
| | - D T Sala
- Emergency Mures County Hospital, Second Department of Surgery, Targu Mures, Romania
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Barczyński M, Dionigi G. New techniques and technologies for the treatment of surgical endocrine diseases. Gland Surg 2016; 5:455-457. [PMID: 27867858 DOI: 10.21037/gs.2016.10.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University, College of Medicine, Kraków, Poland
| | - Gianlorenzo Dionigi
- First Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
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