To identify or not to identify parathyroid glands during total thyroidectomy

The effect of carbon nanoparticles vs. immune colloidal gold technique test strips on parathyroid protection in total thyroidectomy: A randomized clinical trial study

BACKGROUND

The long-term effect of intraoperative usage of carbon nanoparticles (CN) and parathyroid hormone (PTH) test strip using immune colloidal gold technique (ICGT) is unclear. This study aims to compare the effect of intraoperative usage of CN and ICGT test strips on PG function.

METHODS

This randomized clinical study involved adult patients who underwent total thyroidectomy. They were randomly allocated into three groups (control, CN, and ICGT group). Clinical data were analyzed.

RESULTS

Each group involved 98 patients. Serum calcium and PTH concentrations at 24 h postoperatively (PTH24h) were higher in CN group. The parathyroid function recovered quicker in CN group. Use of CN increased in situ PG preservation and PTH24h. Mediation analysis indicated that 23.05% of the total effect of CN on PTH24h was attributed to PGRIS.

CONCLUSION

CN holds promise to improve in situ PG preservation and protect PG vasculature, thereby reducing the incidence of early hypoparathyroidism. The value of ICGT test strips for PG protection is dubious.

5-year Follow-up of Reimplanted Parathyroid Glands in Forearm Subcutaneous Tissue During Thyroidectomy. A Confirmation of Graft Vitality in a Large Series of Patients

INTRODUCTION

The aim of this study is to assess the outcomes of parathyroid gland reimplantation with PR-FaST technique in patients undergoing thyroid surgery, focusing on graft functionality over a 5-year follow-up period.

MATERIALS AND METHODS

We analyzed data from 131 patients who underwent parathyroid reimplantation using the PR-FaST technique during thyroid surgery due to inadvertent parathyroid removal or evident vascular damage. Postoperative evaluations included serum calcium (Ca), magnesium (Mg), and phosphorus (P) analyses on the 1st and 2nd postoperative days, at 10 days, and at 1, 3, 6 months, 1 year, and 5 years of follow-up. Additionally, the mean values of serum intact parathyroid hormone (iPTH) concentration were measured from blood samples collected from both the reimplanted arm (iPTH RA) and non-reimplanted arm (iPTH NRA) within the same period.

RESULTS

Among 131 patients, at 10 days post-surgery, only 46 patients (35.1%) out of 131 exhibited graft viability (iPTH ratio >1.5). This percentage increased to 72.8% (94 patients) after 1 month and further to 87.8% (108 patients) after 3 months post-surgery. At 1 year, 84.7% of patients showed good graft functionality. After 5 years, the percentage remained stable, with graft viability observed in 81.3% of patients. Only 91 of the initial 131 patients completed follow-up up to 5 years, with a dropout rate of 30.5 %.

CONCLUSIONS

Parathyroid reimplantation using the PR-FaST technique is a viable option for patients undergoing thyroidectomy and has been shown to be a reproducible and effective technique in most patients, with sustained graft functionality and parathyroid hormone production over a 5-year follow-up period.

The impact of using near-infrared autofluorescence on parathyroid gland parameters and clinical outcomes during total thyroidectomy: a meta-analytic study of randomized controlled trials

BACKGROUND

The added benefit of using near-infrared autofluorescence (NIRAF) during total thyroidectomy (TT) remains controversial. This study investigated whether or not NIRAF results in improved patient outcomes postoperatively.

MATERIALS AND METHODS

We analyzed 1711 TT patients, reported in nine randomized controlled trials, following a systematic search of five databases. NIRAF was compared to the standard of care (naked eye with/without white light). Outcomes included parathyroid gland (PG) and calcium parameters and other clinical outcomes. For dichotomous outcomes, the log odds ratio (logOR) was calculated, and for continuous outcomes, the crude mean difference (MD) was measured. Sensitivity analysis was performed when heterogeneity was significant. The revised Cochrane risk of bias tool was used to assess the methodological quality.

RESULTS

Compared to the standard of care, the use of NIRAF was associated with a significant reduction in postoperative hypoparathyroidism [logOR=-0.31; 95% CI: -0.57: -0.05], inadvertent PG removal [logOR=-0.93; 95% CI: -1.60: -0.26], and postoperative hypocalcemia [logOR=-0.43 mmol/L; 95% CI: -0.77: -0.09]. It was also associated with significantly higher postoperative PTH levels [MD=4.78 pg/mL; 95% CI: 2.13: 7.43], PG identification rate [logOR=1.02; 95% CI: 0.31: 1.72], postoperative serum calcium [MD=0.05; 95% CI: 0.00: 0.09], and operative time [MD=9.38 minutes; 95% CI: 6.68: 12.09]. No difference was seen regarding PG autotransplantation, length of hospital stay, and hospitalization due to hypocalcemia. Seven trials had low risk and the remainder had some concerns.

CONCLUSION

NIRAF is superior to the naked eye in identifying all four parathyroid glands during total thyroidectomy. The reduced risk of postoperative hypoparathyroidism and hypocalcemia reflected this preservation value. However, it was not associated with a change in the length of hospital stay. Although rare, the readmission rate due to hypocalcemia was similar across both methods.

Intraoperative indocyanine green angiography for predicting postoperative hypoparathyroidism

BACKGROUND

Postoperative hypocalcemia is a common complication of thyroidectomy. This problem is most often associated with accidental devascularization or excision of the parathyroid glands (PG).

AIM

Aim was to study near-infrared (NIR) fluorescent imaging with intraoperative PG indocyanine green (ICG) angiography to help identify and preserve PG during total thyroidectomy in order to avoid postoperative hypocalcemia.

MATERIAL AND METHODS

From 2017 to 2022, a total of 92 patients underwent total thyroidectomy at Odessa Regional Hospital. Indications for surgery were multinodular goiter (n = 42), thyroid cancer (n = 43), and Graves' disease (n = 7). By randomization all patients were divided into two groups: in the control group, 48 patients underwent standard total thyroidectomy, and in the main group, 44 patients underwent NIR-assisted total thyroidectomy with ICG angiography. Serum calcium and parathyroid hormone levels were compared between the two groups of patients in 1, 7-15 days after surgery and then 3, 6 months later.

RESULTS

In the control group, based on a visual assessment of the PG, autotransplantation of the PG was conducted in only five cases. In the second group, autotransplantation was performed in 16 patients. The transient postoperative hypocalcemia was observed in 8 patients of the control group (16, 70%) and in the 2 patients of ICG group (4, 50%) on 5-10 postoperative days. In the first group, 2 patients at 3 months after surgery had permanent hypocalcaemia.

CONCLUSION

NIR fluorescent imaging with intraoperative PG ICG angiography is a safe and an easily repeatable method. This technique provides improved detecting and assessment of the perfusion of the PG. The need for autotransplantation of the PG can be determined more objectively using ICG imaging than simple visualization.

Impact of Clinico Pathological and Surgical Related Risk Factor in Post Operative Hypoparathyroidism in Total Thyroidectomy Patients

Multiple risk factors have been predicted in post operative hypoparathyroidism in total thyroidectomy patients but none have been clearly defined. Present study aims at evaluating the clinic pathological and surgical impact factors in predicting the risk of post operative hypoparathyroidism in thyroidectomy patients. The study was done in Karpaga Vinayaga Institute of Medical Science and Research Centre where Retrospective prospective cohort study who underwent and undergoing total thyroidectomy with or without central neck dissection for both benign and malignant thyroid disorders during 2014 to 2022 was analyzed. The study has analyzed the various risk factors from clinic pathological and surgical skills of identifying the Inferior thyroid artery at its origin and tracing the branches to the parathyroid gland and evaluating the incidence of hypocalcemia in both study and control groups. Two groups were analyzed during the period 2014 to 2022. The study group was included patients with thyroidectomy where ITA were identified and traced up to the parathyroid gland. They were further classified into category A where both sides ITA were identified and saved, category B where only one side was preserved. In control group, the surgery was done only on basis of capsular dissection and peripheral ligation of vessels close to the gland. Total study participants in our study was 416. The overall prevalence of hypocalcemia in our study was 11.4%. The age, gender and pathological variants were comparable between the two groups. Female preponderance (76%) was seen among both the groups. Among total study subjects who underwent total thyroidectomy 44.8% were having multi nodular goitre, 7.3% toxic goitre, 9.8% follicular adenoma, 30.2% papillary carcinoma and 7.9% follicular carcinoma. In our study benign and malignant thyroid disorders had no significant difference. Prevalence of hypocalcemia among control group 14.5% vs study group 3.8%. We found incidence of hypocalcaemia was comparitively lesser among patients with thyroidectomy alone, than those with unilateral or bilateral CND. Prevalence of hypocalcemia among control group was 33% (45/133) and study group 7% (12/153), when thyroidectomy alone was done. However, with neck dissection in bilateral CND, incidence was 41% (23/56) in study group and 61% (11/18) in control group. In unilateral CND, study and control group had 31% (10/32) and 54% (13/24) which was found to be statistically significant. Parathyroid auto transplantation among the control group (29%) compared to the study group (16%). Bilateral neck dissection and gross extrathyroidal extension and cases with PTG inadvertent removal posed significant risk factors for hypoparathyroidism. The prevalence of immediate hypocalcemia among Cat A, Cat B and control group were 14%, 20.3% and 37.5% respectively and was statistically significant (P < .0001). Symptomatic and Biochemical hypocalcemia at the end of 1 week among Cat A, Cat B, and control group was 8%, 12%, and 33.6, & 12.9%, 21% and 30% respectively. Whereas transient hypocalcemia reported among these groups was 1.6%, 5% and 14.6%. Permanent hypocalcemia was < 1% in study group and 4% among control group. We observed that permanent hypocalcemia was high among patients with bilateral neck dissection and auto transplanted PTG. There was no significant statistical difference in hypocalcemia (transient or permanent) among study and control group, but the incidence of hypocalcemia had significantly reduced in both study groups when unilateral or bilateral identification of ITA was done compared to control group. Our hypothesis in this study aims at preserving the branches of ITA supplying PTG distally has greater functional preservation of the parathyroid than conventional technique. This technique also helps us maintaining the plane and capsular dissection if done properly. By trying to preserve the ITA surgeons may acquire better meticulous dissection skills and understanding the anatomical variation of vessels around PTG more precisely which improve the surgical outcome in preventing both transient and permanent hypocalcaemia.

Intraoperative prevention of postoperative hypoparathyroidism

Objective

More than 30,000 thyroid surgeries are performed annually in the Russian Federation. The surgeries are relatively safe because of the prevention methods for postoperative complications. Currently, there is no single effective method of postoperative hypoparathyroidism prevention. This complication is frequently reported and may be health and life-threatening.

Aim

We aimed to estimate the effectiveness of the intraoperative ICG-angiography and intrathyroid injection of Brilliant Green for the prevention of postoperative hypoparathyroidism.

Material and methods

One hundred and forty-three thyroidectomies were performed. Patients were divided into three groups: intraoperative angiography was used in 24 cases; Brilliant Green was injected in 58 cases to identify parathyroid glands; the visual estimation of the parathyroid preservation was used in 61 cases. Calcium level was measured in all patients before and after surgery.

Results

Calcium level in the serum before and after surgery was 2.37±0.14 and 2.27±0.17 in Group 1, 2.38±0.16 and 2.21±0.16 in Group 2, and 2.39±0.17 and 2.18±0.19 in Group 3. Postoperative hypocalcemia was more prominent in the group with the visually estimated PTG than in the two other groups. The differences in postoperative calcium levels in Groups 1 and 3 were statistically different. Pre- and postoperative Parathormone levels were 6.2±0.4 in Group 1, 5.6±0.57 in Group 2, and 3.5±0.32 in Group 3. Postoperative levels significantly differed in Groups 1 and 3 (p<0.01) and in Groups 2 and 3 (p<0.05).

Conclusions

ICG-angiography and intrathyroid injection of the Brilliant Green are safe methods of identification and sparing of the parathyroid glands. The severity of hypocalcemia and hypoparathormonemia in Group 3 shows the necessity of finding new methods in endocrine surgery to improve patient outcomes.

Distribution of inadvertently excised parathyroid glands during thyroid surgery and the link with post-surgical hypoparathyroidism

OBJECTIVES

To evaluate the incidence of inadvertent parathyroidectomy, identify risk factors, determine the location of inadvertently excised glands, review pathology reporting in inadvertent parathyroidectomy, and explore relationships between inadvertent parathyroidectomy and post-surgical hypoparathyroidism or hypocalcaemia.

METHODS

A retrospective cohort study of 899 thyroidectomies between 2015 and 2020 was performed. Histopathology slides of patients who had an inadvertent parathyroidectomy and a random sample of patients without a reported inadvertent parathyroidectomy were reviewed.

RESULTS

Inadvertent parathyroidectomy occurred in 18.5 per cent of thyroidectomy patients. Central neck dissection was an independent risk factor (inadvertent parathyroidectomy = 49.4 per cent with central neck dissection, 12.0 per cent without central neck dissection, p < 0.001). Most excised parathyroid glands were extracapsular (53.3 per cent), followed by subcapsular (29.1 per cent) and intrathyroidal (10.9 per cent). Parathyroid tissue was found in 10.2 per cent of specimens where no inadvertent parathyroidectomy was reported. Inadvertent parathyroidectomy was associated with a higher incidence of six-month post-surgical hypoparathyroidism or hypocalcaemia (19.8 per cent who had an inadvertent parathyroidectomy, 7.7 per cent without inadvertent parathyroidectomy).

CONCLUSION

Inadvertent parathyroidectomy increases the risk of post-surgical hypoparathyroidism or hypocalcaemia. The proportion of extracapsular glands contributing to inadvertent parathyroidectomy highlights the need for preventative measures.

Incidence and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy

PURPOSE

The incidence and risk factors for hypoparathyroidism after total thyroidectomy is well-known. However, the characteristics of hypoparathyroidism and hypocalcemia after hemithyroidectomy have not been investigated well. In this study, we aimed to evaluate the incidence, characteristics, and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy.

METHOD

We retrospectively analyzed the medical data of 321 patients who underwent hemithyroidectomy, with or without central neck dissection, from January 2012 to April 2019. We analyzed the serum intact parathyroid hormone (iPTH), calcium, and ionized calcium (iCa) levels serially (preoperatively and postoperatively on the operation day; days 1 and 3; and months 1, 3, 6, and 12) and evaluated risk factors for postoperative hypoparathyroidism and hypocalcemia.

RESULTS

The mean iPTH and calcium levels decreased significantly after hemithyroidectomy on the operation day and postoperative days 1 and 3, and returned to the preoperative level at the postoperative 1-month follow-up. The mean iCa level decreased significantly on the operation day and postoperative day 1. Transient hypoparathyroidism and transient hypocalcemia occurred in 16 (5%) and 250 (78%) participants, and they recovered to normal levels postoperatively by 1 month. Eight (2.5%) patients had mild symptoms of hypocalcemia necessitating oral calcium supplementation. No permanent hypoparathyroidism or hypocalcemia was observed. Preoperatively low serum iPTH and calcium levels were associated with transient hypoparathyroidism and hypocalcemia after hemithyroidectomy.

CONCLUSION

Approximately 5% and 2.5% of participants showed transient hypoparathyroidism and mild symptomatic hypocalcemia after hemithyroidectomy. The risk factors for transient hypoparathyroidism and hypocalcemia include preoperative low serum iPTH and calcium levels.

Indocyanine green (ICG) angiography-guided thyroidectomy: description of surgical technique

Background

Postoperative hypoparathyroidism is the most common complication after total thyroidectomy and, when becomes permanent, lead to a myriad of clinical symptoms, long-term need of calcium and vitamin D supplementation and negative impact on the patient's health-related quality of life. Any surgical innovation that could reduce complications and improve outcomes of patients undergoing total thyroidectomy deserves to be considered. Angiography-Guided Thyroidectomy has been proposed as a modification of the standard technique of thyroidectomy aimed to identifying the vascular pattern of the parathyroid glands to maximize efforts for preserving functioning glands at the time of operation. Our aim is to provide a technical description of this procedure based on the use of indocyanine green (ICG) angiography to standardize this technique.

Methods

The surgical steps that are followed during a total thyroidectomy are modified due to previous visualization of the feeding vessels of the parathyroid glands according to fluorescence of the vascular mapping obtained by ICG angiography prior to thyroidectomy. The first step is to perform an ICG angiography to assess anatomical features of the feeding vasculature of the parathyroid glands, which allows precise surgical dissection for preservation of the glands. Once the viability of the parathyroids has been evaluated angiographically, thyroidectomy is performed in a second step.

Conclusions

ICG angiography-guided thyroidectomy may be effective to preserve the largest number of better perfused parathyroid glands, which would contribute to reduce the risk of postoperative and permanent hypoparathyroidism. It can be successfully and safely implemented in thyroid surgery and standardization of the technique is necessary to homogenize this procedure in the future, allowing a better comparation of the results to be published.

Preservation of parathyroid glands during thyroid and neck surgery

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.

Incremental value of magnification and indocyanine green for parathyroid preservation in thyroid surgery

BACKGROUND

To assess the promise of surgical magnification and of intraoperative indocyanine green (ICG) assisted near-infrared fluorescence (NIRF) in improving parathyroid identification and viability assessment during thyroidectomy.

METHODS

Prospective comparative study. Parathyroid gland identification sequentially assessed by naked eye, surgical microscopy, and by NIRF imaging following ICG administration (5 mgIV). Parathyroid perfusion/vitality reassessed end-surgery by ICG-NIRF.

RESULTS

An expected total of 104 parathyroid glands were assessed in 35 patients (17 total-thyroidectomy, 18 hemi-thyroidectomy). 54/104 (51.9%) were identified by naked eye, and sequentially greater numbers identified by microscope magnification (n = 61; 58.7%; p = 0.33), and by ICG-NIRF (n = 72; 69.2%; p = 0.01). ICG-NIRF detected additional parathyroid glands in 16/35 patients (45.7%). Confident identification of at least one parathyroid remained unachieved in 5/35 by naked eye, in 4/35 by microscopic magnification, and in no patient by ICG-NIRF. ICG-NIRF indicated end-of-surgery devascularization in 12/72 glands and informed decisions regarding gland implantation.

CONCLUSION

Significantly greater parathyroid glands are identified and preserved with surgical magnification and with ICG-NIRF. Both techniques merit routine adoption for thyroidectomy.

Effect of near infrared autofluorescence guided total thyroidectomy on postoperative hypoparathyroidism: a randomized clinical trial

PURPOSE

The purpose of this single-blinded, 2-centre, randomized controlled trial was to test if near-infrared (NIR) autofluorescence image guidance for parathyroid gland (PG) detection during total thyroidectomy can reduce the incidence of hypoparathyroidism in both malignant and benign cases.

METHOD

Patients admitted for primary or completion total thyroidectomy were randomized to either the NIR intervention group or the standard care NONIR (no near infrared) group. The primary endpoint was the rate of hypoparathyroidism at the 3-month follow-up, defined as hypocalcemia and inappropriately low parathyroid hormone levels and/or continuous treatment with active vitamin D. The secondary endpoint was the PG identification rate.

RESULTS

A total of 147 patients were included of whom 73 were allocated to NIR. Primary or completion thyroidectomy was conducted in 84 and 63 cases, respectively. A total of 130 completed 3 months follow-up. Postoperative hypoparathyroidism in the NIR group at 12 h, 1 month and 3 months was, respectively, 31.8, 14.1, 6.5% compared with 35.9, 18.9, 11.8% in the NONIR group (all p > 0.46). In the NIR group, the identification rate of PGs was 69.5% (146 of 210 PGs), and 9% (19 of 210 PGs) were identified only due to additional use of NIR. For 15 out of 69 patients (21.7%) additionally PGs was found.

CONCLUSION

Hypoparathyroidism was nominally less frequent in the NIR group, although not statistically significant. Further studies are needed to confirm if NIR may be a supportive PG identification tool to minimize the number of PG which would have been otherwise missed, especially during more complicated thyroid procedures.

TRIAL REGISTRY

ClinicalTrials.gov: NCT04193332. Registration date: 16.08.2019.

Usefulness of ICG Angiography-Guided Thyroidectomy for Preserving Parathyroid Function

INTRODUCTION

Hypoparathyroidism is the most frequent complication after total thyroidectomy and, when permanent, it becomes a severe chronic disease. We assessed the usefulness of indocyanine green (ICG) angiography-guided thyroidectomy to reduce the postoperative hypocalcemia.

METHODS

Prospective study with two consecutive cohorts of patients who underwent total thyroidectomy: historical control group (CG) and angiography-guided thyroidectomy group (AG). In all patients, ICG-angiography was performed at the end of the surgery to predict immediate parathyroid gland (PG) function. In the AG, ICG-angiography was also done after PG identification to show their vascular supply. We compared the rate of postoperative hypocalcemia (calcium supplementation needed due to hypocalcemia symptoms or calcium levels < 1.8 mmol/L on the first postoperative day) and permanent hypocalcemia (need of calcium ± vitamin D supplementation 12 months after thyroidectomy).

RESULTS

We included 120 consecutive patients (84 CG; 36 AG). Thyroid cancer was the most common diagnostic (63.1% CG-69.4% AG; p = 0.646) and central neck dissection was also frequent (54.8% CG-64.3% AG; p = 0.468). The AG developed a lower rate of postoperative (26.2-5.6%; p = 0.011) and permanent hypocalcemia (11.9-0%; p = 0.032). The OR for permanent hypocalcemia was 0.673 (95% CI 0.591-0.766). A significant higher rate of well vascularized PG at the end of the surgery (score 2) in the AG (39.2-52.9%; p = 0.018) was also seen.

CONCLUSION

ICG angiography-guided thyroidectomy is a useful tool to identify PG vascularization, allowing a better PG preservation and a significant decrease in hypocalcemia rates.

[Indocyanine green fluorescence angiography in transoral endoscopic thyroidectomy for papillary thyroid cancer]

OBJECTIVE

To evaluate the effectiveness of ICG angiography in patients with papillary thyroid cancer (PTC) undergoing transoral endoscopic thyroidectomy (TOETVA) and selective neck dissection (level VI).

MATERIAL AND METHODS

A retrospective analysis included 20 patients with PTC who underwent TOETVA with selective neck dissection (level VI) between September and December 2022. ICG was administered intravenously (5 mg ´ 3 times). We analyzed parathyroid glands by visual examination and ICG angiography. Fluorescence of all glands was assessed.

RESULTS

Twenty patients underwent ICG angiography during TOETVA. A total of 68 parathyroid glands were identified. Only 76.5% (52/68) of parathyroid glands were identified at initial visual examination. ICG angiography additionally localized 12 glands that improved detection to 94.1% (64/68). At least one well-vascularized parathyroid gland was demonstrated by ICG angiography in 16 patients. In all these patients, serum parathyroid hormone was normal in 1 and 10 days after surgery. Two out of four patients who failed to identify a well-vascularized parathyroid gland developed transient hypoparathyroidism. There were no intraoperative and postoperative complications associated with ICG angiography.

CONCLUSION

ICG angiography was simple, safe and effective for better identification and preservation of parathyroid glands in patients with PTC undergoing TOETVA. This method was valuable for assessing the viability and function of parathyroid glands and predicting postoperative hypocalcemia.

Safe thyroid surgery: comparison effectiveness of ICG angiography and intrathyroidal brilliant green injection for the prevention of postoperative hypoparathyroidism

BACKGROUND: More than 30,000 surgical interventions on the thyroid gland are performed annually in the Russian Federation. Surgeons are developing methods for the prevention of various postoperative complications, and therefore operations on this organ are considered relatively safe. Currently, there is no unequivocal effective method to prevent postoperative hypoparathyroidism. This complication is often recorded and can threaten the life and health of the patient, which is contrary to the concept of safe surgery.

AIM: To evaluate the effectiveness of intraoperative ICG angiography and intrathyroidal injection of brilliant green for the prevention of postoperative hypoparathyroidism.

MATERIALS AND METHODS: 143 thyroidectomies were performed. The patients were divided into 3 groups: intraoperative angiography was used in 24 cases, brilliant green was injected to identify the parathyroid glands in 58 cases, visual assessment of the preservation of the parathyroid glands was used in 61 case. Calcium levels were measured in all patients included in the study before and after surgery.

RESULTS: Serum calcium levels in the pre- and postoperative period: 2.37±0.14 and 2.27±0.17 in group 1, and 2.38±0.16 and 2.21±0.16 in group 2, 2.39±0.17 and 2.18±0.19 in group 3. Hypocalcemia in the postoperative period was significantly higher in the group with a visual assessment of the parathyroid glands relative to the first two groups. Differences between calcium levels in the postoperative period in groups 2 and 3 were significant with a probability of more than 99% (p<0.01). Significant differences (≥95%) in calcium levels in the postoperative period between groups 1 and 2 (p < 0.05) were obtained. Serum PTH levels in the postoperative period: 6,2±0,4 in group 1, 5,6±0,57 in group 2, 3,5±0,32 in group 3. Differences between PTH levels in the postoperative period in groups 1 and 3 were significant with a probability of more than 99% (p<0.01). Significant differences (≥95%) in PTH levels in the postoperative period between groups 2 and 3 (p < 0.05) were obtained.

CONCLUSION: ICG angiography and brilliant green intrathyroidal injection are safe methods for identifying and preserving the parathyroid glands. The high level of hypocalcemia in group 3 indicates the need to search for new techniques in endocrine surgery in order to improve the safety of patients undergoing surgical treatment of thyroid pathology.

Near-infrared fluorescent imaging techniques for the detection and preservation of parathyroid glands during endocrine surgery

Objectives

In over 30% of all thyroid surgeries, complications arise from transient and definitive hypoparathyroidism, underscoring the need for real-time identification and preservation of parathyroid glands (PGs). Here, we evaluate the promising intraoperative optical technologies available for the identification, preservation, and functional assessment of PGs to enhance endocrine surgery.

Methods

We performed a review of the literature to identify published studies on fluorescence imaging in thyroid and parathyroid surgery.

Results

Fluorescence imaging is a well-demonstrated approach for both in vivo and in vitro localization of specific cells or tissues, and is gaining popularity as a technique to detect PGs during endocrine surgery. Autofluorescence (AF) imaging and indocyanine green (ICG) angiography are two emerging optical techniques to improve outcomes in thyroid and parathyroid surgeries. Near-infrared-guided technology has significantly contributed to the localization of PGs, through the detection of glandular AF. Perfusion through the PGs can be visualized with ICG, which can also reveal the blood supply after dissection.

Conclusions

Near infrared AF and ICG angiography, providing a valuable spatial and anatomical information, can decrease the incidence of complications in thyroid surgery.

Biodegradable iron oxide nanoparticles for intraoperative parathyroid gland imaging in thyroidectomy

Parathyroid gland (PG) injury is the most common complication of thyroidectomy owing to the lack of approaches for surgeons to effectively distinguish PGs from surrounding thyroid glands (TGs) in the operation room. Herein, we report the development of biodegradable iron oxide nanoparticles (IONPs) as a promising contrast agent candidate for intraoperative PG visualization. We elucidated that locally administrated dark-colored IONPs readily diffuse in TGs but cannot infiltrate tissue-dense PGs, yielding a distinguishable contrast enhancement between PGs and TGs by naked eye observation. We performed unbiased and quantitative in vivo screenings to optimize particle size and concentration of IONPs for PG/TG contrast enhancement. Moreover, in vivo applications of IONPs via the local administration route demonstrate no adverse toxicities and can be biodegraded in the thyroid microenvironment within 3 months. To our knowledge, these promising findings provide the first in vivo evidence that IONPs can serve as a safe, biodegradable, and effective contrast agent candidate for improving PG visualization in thyroidectomy.

The Russian Registry of Chronic Hypoparathyroidism

INTRODUCTION

Chronic hypoparathyroidism is a relatively rare disease associated with multicomponent medical therapy and various complications. The analysis of large databases of patients with chronic hypoparathyroidism is a necessary tool to enhance quality of medical care, as well as to determine the optimal clinical and therapeutic approaches, and prognostic markers of the disease.

THE AIM

of this study is to estimate the clinical and biochemical profile, long-term complications, medical therapy and disease control of the patients with chronic postsurgical and non-surgical hypoparathyroidism.

MATERIALS AND METHODS

the cross-sectional, observational, continuous study was based on the Russian Registry of patients with hypoparathyroidism. 544 patients from 63 regions of the Russian Federation were included in this study.

RESULTS

The majority of cases had postsurgical etiology (88.4%). Postsurgical hypoparathyroidism prevailed in females (р<0.001). About a half of patients had blood calcium and phosphorus targets, 56 and 52% respectively. Nephrolithiasis was confirmed in 32.5%, nephrocalcinosis - in 12.3% of cases. The risk of nephrocalcinosis/nephrolithiasis increased by 1.85 times with disease duration more than 4.5 years. The cataract was found in 9.4%. The cut-off point for the development of cataracts was 9.5 years, with a 6.96-fold increased risk. The longer duration of hypoparathyroidism of any etiology was associated with more frequent cataract (p=0.0018).We found brain calcification in 4%, arrhythmias in 7.2% and neuropsychiatric symptoms in 5.15% of cases. Generally, the BMD in the studied group corresponded to age values, and there was no evidence for the phenomenon of high bone density. TBS was consistent with normal bone microarchitectonics. In our study, the majority of patients (83.5%) was treated with standard therapy of calcium and vitamin D supplements. 5 patients with severe disease course were treated with rhPTH (1-34).

CONCLUSIONS

Analysis of the presented database indicates insufficient diagnosis of the complications associated with chronic hypoparathyroidism. Overall, hypoparathyroidism is associated with higher risks of renal stone formation, decreased GFR, cataract especially in patients with longer duration of disease.

[Prevention and treatment of postoperative hypoparathyroidism]

Hypoparathyroidism is a failure of parathyroid glands characterized by reduced serum concentration of parathyroid hormone, hypocalcemia and hyperphosphatemia. The most common cause of hypoparathyroidism is resection or damage to parathyroid glands during thyroid surgery. Postoperative hypoparathyroidism is still an urgent problem, as it requires additional treatment and prolongs hospital-stay. Considering available literature data, the authors analyze various methods of intraoperative prevention of hypoparathyroidism.

Thyroidectomy for Cancer: The Surgeon and the Parathyroid Glands Sparing

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.

Near-Infrared Autofluorescence Imaging May Reduce Temporary Hypoparathyroidism in Patients Undergoing Total Thyroidectomy and Central Neck Dissection

Background: Near-infrared autofluorescence (NIRAF) imaging is known to reduce the incidence of post-thyroidectomy hypocalcemia. However, there are no studies on how much NIRAF imaging affects the serum parathyroid hormone (PTH) level after surgery. We investigated the changes of the serum PTH level and ionized calcium (iCa.) in patients undergoing total thyroidectomy with central neck dissection (CND). Materials and Methods: This retrospective study with historical control enrolled 542 patients who underwent total thyroidectomy with CND. Patients were divided into two groups: the NIRAF group (261 patients) and the control group (281 patients). PTH and iCa. levels were measured at the hospital stay, 1, 3, and 6 months after surgery. In addition, the number of identified parathyroid glands (PGs), autotransplanted PGs, and the inadvertent resection rate of PGs was evaluated. Results: The incidence of postoperative hypoparathyroidism (PTH <15 pg/mL) was significantly lower in the NIRAF group during the hospitalization (88 patients: 33.7% vs. 131 patients: 46.6%; p = 0.002) and at 1 month postoperatively (23 patients: 8.8% vs. 53 patients: 18.9%; p = 0.001). There was no difference in the permanent hypoparathyroidism rate (6 months after surgery) between the NIRAF group and the control group (4.2% vs. 4.6%; p = 0.816). There was no difference in the incidence of hypocalcemia (iCa. <1.09 mmol/L) (during hospitalization: 6.5% vs. 10.0%; 1 month: 2.3% vs. 2.5%; 3 months: 0.8% vs. 0.7%; 6 months after surgery: 1.1% vs. 1.1%) between the two groups. The number of inadvertently resected PGs was significantly lower in the NIRAF group (18:6.9% vs. 36:12.8%; p = 0.021). Conclusions: These results suggest that NIRAF imaging may reduce temporary hypoparathyroidism and the risk of inadvertent resection of PGs in patients undergoing total thyroidectomy with CND.

[Review of clinical practice guidelines for hypoparathyroidism]

Hypoparathyroidism is a rare disorder characterized by the absent or inappropriately decreased serum parathyroid hormone in the parathyroid glands, which is accompanied by impaired calcium-phosphorus metabolism.The main etiology of hypoparathyroidism remains damage or removal of the parathyroid glands during neck surgery. In view of the incidence of thyroid cancer, primary hyperparathyroidism and other pathologies of the neck organs, which radical treatment can lead to the parathyroid gland impairment, an increased number of patients with hypoparathyroidism is expected. Autoimmune hypoparathyroidism is the second most common form of the disease, usually occurring as part of type 1 autoimmune polyglandular syndrome. Autoimmune hypoparathyroidism usually occurs in childhood and is characterized by a severe course of the disease, especially in the case of concomitant malabsorption syndrome.Chronic hypoparathyroidism of any etiology requires lifelong multicomponent therapy, as well as careful monitoring and an individual approach to choose the optimal treatment strategy. In the absence of adequate follow-up, the risks of long-term complications significantly increase, particularly in the renal, cardiovascular systems; in the soft tissues and in the brain, it could lead to visual disturbances; pathology of the musculoskeletal system with a decreased bone remodeling and a potential risk of fractures, as well as to the neurocognitive disorders and an impaired health-related quality of life.Timely diagnosis, rational medical therapy and management strategy may reduce the risks of short-term and long-term complications, frequency of hospitalizations and disability of patients, as well as improve the prognosis.This review covers the main issues of Russian guidelines for the management of chronic hypoparathyroidism, approved in 2021, including laboratory and instrumental evaluation, treatment approaches and follow-up. This guidelines also include the recommendations for special groups of patients: with acute hypocalcemia, hypoparathyroidism during pregnancy.

The long-term need for calcium supplementation after incidental parathyroidectomy

Objectives

Methods

Results

Conclusion

Total thyroidectomy with intraoperative neural monitoring and near-infrared fluorescence imaging

PURPOSE

To describe our personal experience during aclassic complete thyroidectomy adopting both intraoperative neural monitoringand near-infrared autofluorescence.

METHODS

In October 2021, 20 patients underwent totalthyroidectomy for benign and malignant conditions: 13 patients were affected bymultinodular goiter, 2 by Graves' disease, and 5 by indeterminate lesions (3Tir-3B and 2 Tir-3A). For each patient, intraoperative neural monitoring of therecurrent laryngeal nerve and near-infrared autofluorescence were used.

RESULTS

Overall, 76/80 (95.0%) parathyroid glands weredetected: 34/76 (44.7%) were identified by the surgeon during the dissection,while 42/76 (55.3%) were detected by the near-infrared camera before thesurgeon saw them with naked eye. Indocyanine green angiography was adopted inall the patients, and in 2 cases, parathyroid gland autotransplantation wasperformed since 2 parathyroid glands resulted devascularized after dissection.Operative time ranged from 113 to 201 min (mean 156 min).

CONCLUSION

Together with intraoperative neural monitoring,near-infrared autofluorescence is a reliable device in thyroid surgery. Furtherprospective studies are necessary to establish if the adoption ofautofluorescence may result in long-term benefit in terms of calcemia.

Potential protection of indocyanine green on parathyroid gland function during near-infrared laparoscopic-assisted thyroidectomy: A case report and literature review

BACKGROUND

In recent decades, significant advances have been made in protecting the parathyroid glands and recurrent laryngeal nerves during thyro-idectomy. However, reliable and convenient technical means are still lacking. In this study, the reliability, safety and feasibility of near-infrared (NIR) laparoscopy-assisted thyroid lobectomy with isthmectomy and prophylactic central lymph node dissection (CLND) were reported.

CASE SUMMARY

A 63-year-old female patient with a free previous medical history, was admitted to our department due to multiple thyroid nodules. Ultrasonic examination suggested diffuse thyroid changes and one thyroid nodule in the right upper lobe with the largest diameter of 1.5 cm adjacent to the trachea and Breast Imaging Reporting and Data System grade 4B. Imaging examination of the neck showed no obvious enlarged lymph nodes. Fine needle aspiration biopsy suggested a papillary thyroid carcinoma. Combined with thyroid function examination, the patient was diagnosed with papillary thyroid carcinoma and Hashimoto's thyroiditis. Considering the risk of invading the capsule and the patient's extreme anxiety, a right thyroid lobectomy with isthmectomy and prophylactic CLND was planned. No significant abnormalities were found during preoperative examinations, except for an increased thyroid stimulating hormone level. The patient underwent NIR laparoscopy-assisted thyroid lobectomy with isthmectomy and prophylactic CLND. During the operation, two right parathyroid glands (PGs) adjacent to the thyroid gland capsule and the right recurrent laryngeal nerve (RLN) were examined by indocyanine green (ICG) fluorescence using a NIR fluorescence camera, and the PGs and RLN were reliably preserved. Considering the ICG-positive PG, prophylactic CLND was performed. The postoperative parathyroid hormone level was in the normal range and no significant hypocalcemia symptoms were observed.

CONCLUSION

During NIR laparoscopy-assisted thyroidectomy, ICG fluorescence may aid PG identification and protection.

Development and validation of a new model for predicting hypocalcaemia after total thyroidectomy: the NuGra model

BACKGROUND

Hypocalcaemia is the most frequent complication after total thyroidectomy. Finding a method for its early detection has become a priority. A single-center prospective cohort study was conducted to identify risk factors for postoperative hypocalcaemia, develop an early detection model, and test its validity in a different group of patients.

METHODS

The sample was composed of patients who underwent a total thyroidectomy between May 2012 and September 2015. Demographic, clinical, laboratory, and surgical data were collected. The incidence of hypocalcaemia and permanent hypoparathyroidism was calculated. Bivariate and multivariate analysis identified several independent predictors of hypocalcaemia, which were used to design a predictive model. The validity of the model was subsequently tested in a different cohort. Area under the ROC curve (AUROC) was calculated to determine its predictive power.

RESULTS

The study and validation groups included 352 and 118 patients, respectively. Seventy-three patients developed laboratory-confirmed hypocalcaemia (20.7%), and symptomatic in 43 (12.2%). Multivariate analysis confirmed as independent predictors of hypocalcaemia the higher number of parathyroid glands identified [OR 1.41(0.98, 2.02); p = 0.063] and pre-to-postoperative gradient of parathormone decline [OR 1.06(1.04, 1.08); p < 0.001]. Based on these variables, the NuGra (Number of parathyroid glands identified-Gradient of decline) model was developed for predicting laboratory-confirmed hypocalcaemia. Its predictive power was high (AUROC 0.902, CI 0.857-0.947) for the study and the validation group (AUROC 0.956, CI 0.919-0.993).

CONCLUSIONS

A higher number of parathyroid glands identified and a higher gradient of parathormone decline are risk factors for post-thyroidectomy hypocalcaemia. The NuGra model is useful for early prediction of individual risk for hypocalcaemia.

Identification of inadvertently removed parathyroid glands during thyroid surgery using autofluorescence

Background

Incidental excision of parathyroid glands is a common event during thyroid surgery and in spite the divergent results that can be obtained from the literature about its clinical significance, all efforts must be used to their preservation. Due to the autofluorescence emitted by parathyroid glands, authors began to use a custom device to inspect thyroidectomy specimens for incidentally removed parathyroid tissue; the results of using this device are presented in this manuscript.

Methods

Specimens of 40 consecutive thyroid surgeries were inspected. Localization of suspect high-fluorescence spots were recorded for confirmation with a pathological exam. Determinations of calcium and parathyroid hormone (PTH) were completed prior to surgery and at 24 hours and 15 days after the operation.

Results

Patient age ranged from 36 to 83 years and were predominantly female (82.5%). Calcium values at 24 hours post-operation varied between 7.1 and 9.5. The PTH values ranged between 3 and 77. Thirteen patients (32.5%) presented with biochemical hypocalcemia at 24 hours. At 15 days after the operation, only one patient presented with a calcium value below 8 (PTH: 10.9) with complete normalization 6 months after the surgery. Pathological examination identified eight parathyroid fragments in seven patients. There was no correlation between the presence of parathyroid tissue in the specimen and post-operative hypocalcemia (P=0.254). Eight suspicious areas of augmented fluorescence where detected; seven were coincident with the pathological examination and one was a false positive. One intrathyroidal gland was not identified, resulting a sensitivity of 87.5% and specificity 96.2%.

Conclusions

Although no correlation between incidental parathyroidectomy and hypocalcemia was demonstrated, autofluorescence may be a useful tool for in-table identification of incidentally-removed glands.

Giant toxic multinodular goiter with dyspnea: A case report

•

This case report mainly focus on a case of 47-year old female with multinodular goiter.

•

Fine Needle Aspiration Cytology needs to be done from the suspicious nodule.

•

Toxic MNG is most effectively treated by total thyroidectomy, which achieves complete diminution from symptoms.

•

Surgery for huge goiter is challenging particularly on difficult intubation, altered anatomy, supraglottic edema and adhesions.

Introduction

Toxic multinodular goiter (MNG) involves an enlarged thyroid gland, is a common cause of hyperthyroidism and when it is accompanied by obstructive symptoms such as dyspnea, it carries an indication for surgery.

Case presentation

We present a case of 47-year old female with multinodular goiter with a rapid increase in size within 2 years. She also reported palpitation, breathlessness on exertion, tachycardia and hand tremor. Computed tomography scan of the neck shows a gross enlargement of thyroid gland across both sides of the neck. The fine needle aspiration cytology and final histopathological examination were suggestive of MNG with adenomatous nodules and toxic changes respectively. A total thyroidectomy was performed and the gland was dissected successfully.

Discussion

Toxic MNG is most effectively treated by total thyroidectomy, which achieves complete diminution from symptoms.

Conclusion

Surgery for huge goiter is challenging and one should be careful about difficult intubation, altered anatomy and adhesions to the surrounding structures. Recognizing and treating this kind of cases are important, as they constitute a preventable cause of mortality if timely diagnosed and treated.

The predictive factors for postoperative hypoparathyroidism and its severity on the first postoperative day after papillary thyroid carcinoma surgery

PURPOSE

The purpose of the study was to investigate the predictive factors for hypoparathyroidism and its severity on the first postoperative day (POD1) after total thyroidectomy (TT) with or without central neck dissection (CND) in patients with papillary thyroid carcinoma (PTC).

METHODS

From February 2014 to February 2019, 2550 PTC patients were admitted to our department. PTC patients who underwent TT were enrolled in this study. A parathyroid hormone (PTH) level lower than 15 pg/mL on POD1 was defined as hypoparathyroidism, and the severity of hypoparathyroidism was classified into three categories according to the level of PTH on POD1: mild hypoparathyroidism (10 pg/mL ≤ PTH < 15 pg/mL), moderate hypoparathyroidism (5 g/mL ≤ PTH < 10 pg/mL), and severe hypoparathyroidism (PTH < 5 pg/mL). Multiple clinical, pathological and surgical parameters of these two different groups were compared and analyzed to demonstrate the possible causes of hypoparathyroidism. Furthermore, patients who developed postoperative hypoparathyroidism were also included in a subgroup analysis according to the severity of their hypoparathyroidism. The underlying factors affecting different severities of hypoparathyroidism were also illustrated with univariate and multivariate analyses.

RESULTS

Ultimately, 690 patients who underwent TT were enrolled in this retrospective study. Through the univariate analysis, different surgeons (P < 0.001), extent of CND (P = 0.009), prophylactic calcium supplementation (PCS) (P < 0.001), preoperative (pre-op) PTH level (P < 0.001), and pre-op phosphorus concentration (P = 0.022) were found to be significantly correlated with postoperative hypoparathyroidism. According to the multivariate analysis, PCS was the only independent high-risk factor for hypoparathyroidism. In the univariate analysis of patient subgroups with different severities of hypoparathyroidism, we demonstrated that the tumor T stage (P = 0.021) and pre-op PTH level (P < 0.001) were associated with the severity of hypoparathyroidism. Furthermore, after the multivariate analysis, hypertension (P < 0.001) and pre-op PTH (P < 0.001) were the two independent predictive factors for the severity of hypoparathyroidism after surgery.

CONCLUSIONS

Postoperative PCS could increase the risk for PTC patients developing hypoparathyroidism after thyroid surgery. Patients with a history of hypertension and a relatively high pre-op PTH level may not develop severe hypoparathyroidism after TT with CND.

Intraoperative Indocyanine Green (ICG) Angiography for the Identification of the Parathyroid Glands: Current Evidence and Future Perspectives

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.

Do carbon nanoparticles really improve thyroid cancer surgery? A retrospective analysis of real-world data

Background

Parathyroid protection and central neck dissection (CND) are basic points of thyroid cancer surgery and draw persistent concern. We aimed to evaluate the value of carbon nanoparticles (CNs) for parathyroid gland protection and CND in thyroid surgery for thyroid cancer patients.

Methods

A total of 386 consecutive thyroid cancer patients were enrolled in the retrospective study. Three hundred thirty-four patients using CNs intraoperatively were included in the CN group, and 52 patients without using CNs or any other helping agent were included in the control group. Intact parathyroid hormone (iPTH) was examined. Medical records and histopathologic reports were reviewed. Histopathologic examination was performed.

Results

There were no statistical significances in demographic and basic surgical information, preoperative iPTH, and serum calcium between the two groups (P > 0.05). In the CN group, the thyroid tissue and central neck lymph nodes were stained black by CNs, while the parathyroid glands were not. Histopathological examination showed that the carbon nanoparticles might accumulated in the subcapsular sinus of lymph nodes compared with the none-stained samples. The staining with CNs did not impact the histopathological examination. There were no significant differences in postoperative hypocalcemia and hypoPT at day 1, 1 month, and half year after surgery between the two groups, respectively. There was a big decline of iPTH level after surgery, whereas the perioperative decreasing amplitude of PTH was not statistically different between the CNs and control group (57.2 ± 28.6 vs 55.7 ± 27.8, P = 0.710). There were 43 patients occurring incidental parathyroidectomy in the CN group (43/334, 12.9%) and 7 patients in the control group (7/52, 13.5%), without significant difference (P = 0.907). There was no significant difference in the number of lymph nodes identified by pathology per patient between the CNs and control group regardless of unilateral and bilateral CND.

Conclusions

Carbon nanoparticles help highlight parathyroid glands and lymph nodes in thyroidectomy, but generate no significant benefit for parathyroid glands protection and lymph node dissection. The value of carbon nanoparticles in thyroid cancer surgery should not be exaggerated and needs further evaluation.

Ultrasonic scalpel with knot tying protects parathyroid function for total thyroidectomy with central neck dissection

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.

Central Compartment Nodal Bulk: A Predictor of Permanent Postoperative Hypocalcaemia

Central compartment clearance (CCC) for Papillary thyroid cancers (PTC) is one of the factors causing postoperative hypocalcaemia. We aimed to examine determinants of this major sequela. 41 patients treated for PTCs between 2014 and 2016 were studied. Surgical details, tumour and nodal characteristics, incidence of transient, temporary and permanent hypocalcaemia were noted. Central clearance was done bilaterally in 24 (58.5%) cases, ipsilaterally in 17 (41.6%). Central nodes were involved in 26 (63.4%) cases, unilaterally in 15 (36.6%), bilaterally in 11 (26.8%). Transient hypocalcaemia developed in 10 (24.4%) cases, temporary hypocalcaemia in 6 (14.6%) cases, and permanent hypocalcaemia in 2 (4.9%) cases. 17 (41%) patients were symptomatic. 9 (21.9%) patients received intravenous calcium. The only factor consistently associated with development of hypocalcaemia of all patterns, was the presence of matted central compartment nodes (p = 0.021). Matted nodes also related to a longer length of stay (p = 0.04) and requirement of intravenous calcium (p = 0.000). Extent of CCC, nodal yield, nodal positivity, perinodal extension, number of parathyroids identified, gender or pT size were not significantly associated. Symptomatic patients did not necessarily become permanently hypocalcaemic (p = 0.8). Patients requiring intravenous calcium were more likely to take oral calcium after discharge (p = 0.002). Postoperative hypocalcaemia is more likely in cases with bulky involved central nodes where extensive clearance is done. In routine CCC, even if done bilaterally, preservation of parathyroid function is possible. Permanent hypocalcaemia after CCC need not be taken as inevitable.

Impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy

OBJECTIVES

To determine the impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy.

MATERIAL AND METHODS

A single-center retrospective study was conducted for a 5-year period in a university hospital center, including 605 patients undergoing total thyroidectomy, 52 of whom had mediastinal-recurrent cellular and lymph-node dissection.

ENDPOINTS

The main endpoint was intraoperative number of parathyroid glands as predictor of parathyroid hormone (PTH) level and postoperative hypocalcemia. The secondary endpoint was the correlation between associated mediastinal-recurrent cellular and lymph-node dissection and incidental parathyroidectomy and its impact on PTH level and calcemia in the immediate postoperative period and at 1 month.

RESULTS

161 patients (26.61%) showed hypocalcemia in the immediate postoperative period and 12 (1.98%) at 1 month. Mediastinal-recurrent cellular and lymph-node dissection increased incidental parathyroidectomy risk 4.6-fold. Mediastinal-recurrent cellular and lymph-node dissection was associated with a statistically "suggestive" decrease in day-1 calcemia (P=0.03), and no significant decrease at 1 month (P=0.52). Incidental parathyroidectomy (6.7% of cases with parathyroidectomy versus 1.3% without) did not significantly increase the rate of early hypocalcemia (P=0.28), but was associated with a "suggestive" worsening at 1 month (P=0.02).

CONCLUSION

Hypocalcemia after total thyroidectomy is a complex, probably multifactorial issue. Systematic parathyroid gland identification is not recommended due to the increased risk of gland lesion, mainly by devascularization. Incidental parathyroidectomy may induce hypocalcemia at 1 month postoperatively (statistically "suggestive" association).

Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands

BACKGROUND

Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation.

PATIENTS AND METHODS

We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05.

RESULTS

Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02).

CONCLUSIONS

Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).

Feasibility of using colloidal gold immunochromatography for point-of-care identification of parathyroid glands during thyroidectomy

AIM

To determine the feasibility of using colloidal gold immunochromatography for rapid identification of parathyroid glands during thyroidectomy.

MATERIAL AND METHODS

127 patients undergoing thyroidectomy were randomly divided into PTH-ICGT group (64 cases) and conventional naked eye group (63 cases). The rate of identification of parathyroid glands and the incidence of hypoparathyroidism were compared between the two groups.

RESULTS

PTH-CGI assay results showed that PTH concentration in the parathyroid tissue was (955.3 ± 16.1) ng/L; skeletal muscle tissue [(14.5 ± 1.5) ng/L], thyroid tissue [(15.0 ± 1.3) ng/L], adipose tissue [(15.3 ± 1.2) ng/L], lymph node tissue [(14.0 ± 1.2) ng/L];PTH levels in parathyroid tissues were compared with PTH levels in skeletal muscle, thyroid, fat, and lymph node tissues, respectively. The differences were statistically significant(t values were 23.62, 33.42, 39.34, 30.77, P < 0.0001, respectively); Among the 127 patients undergoing total thyroidectomy, the rate of detection of parathyroid glands was 92.7% in the conventional naked eye group and 96.4% in the PTH-ICGT group. There was no significant difference in the detection rate of parathyroid gland between the two groups (χ2 = 0.7067, P = 0.40). The incidence of temporary hypoparathyroidism after surgery in both groups was 11.3% and 5.7%, respectively (χ2 = 1.093, P > 0.05). The incidence of postoperative permanent hypoparathyroidism in both groups was 3.8% and 0, respectively (Fisher's exact test, P = 0.495).

CONCLUSION

PTH-CGI has a high efficiency in identifying parathyroid glands, which may increase the rate of clinical parathyroid detection and reduce the incidence of postoperative hypoparathyroidism.