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Frontiers in Endocrinology 2023
Topics: Humans; Parathyroid Diseases; Parathyroid Glands
PubMed: 38027097
DOI: 10.3389/fendo.2023.1323778 -
Biomedical Engineering Online Jun 2022Near-infrared (NIR) autofluorescence detection is an effective method for identifying parathyroid glands (PGs) in thyroidectomy or parathyroidectomy. Fiber optical...
BACKGROUND
Near-infrared (NIR) autofluorescence detection is an effective method for identifying parathyroid glands (PGs) in thyroidectomy or parathyroidectomy. Fiber optical probes provide quantitative autofluorescence measurements for PG detection owing to its high sensitivity and high excitation light cut-off efficiency at a fixed detection distance. However, an optical fiber probe lacks the imaging capability and cannot map the autofluorescence distribution on top of normal tissue background. Therefore, there is a need for intraoperative mapping of PGs with high sensitivity and imaging resolution.
METHODS
We have developed a fluorescence scanning and projection (FSP) system that combines a scanning probe and a co-axial projector for intraoperative localization and in situ display of PGs. Some of the key performance characteristics, including spatial resolution and sensitivity for detection, spatial resolution for imaging, dynamic time latency, and PG localization capability, are characterized and verified by benchtop experiments. Clinical utility of the system is simulated by a fluorescence-guided PG localization surgery on a tissue-simulating phantom and validated in an ex vivo experiment.
RESULTS
The system is able to detect indocyanine green (ICG) solution of 5 pM at a high signal-to-noise ratio (SNR). Additionally, it has a maximal projection error of 0.92 mm, an averaged projection error of 0.5 ± 0.23 mm, and an imaging resolution of 748 μm at a working distance ranging from 35 to 55 cm. The dynamic testing yields a short latency of 153 ± 54 ms, allowing for intraoperative scanning on target tissue during a surgical intervention. The simulated fluorescence-guided PG localization surgery has validated the system's capability to locate PG phantom with operating room ambient light interference. The simulation experiment on the PG phantom yields a position detection bias of 0.36 ± 0.17 mm, and an area intersection over unit (IoU) of 76.6% ± 6.4%. Fluorescence intensity attenuates exponentially with the thickness of covered tissue over the PG phantom, indicating the need to remove surrounding tissue in order to reveal the weak autofluorescence signal from PGs. The ex vivo experiment demonstrates the technical feasibility of the FSP system for intraoperative PG localization with accuracy.
CONCLUSION
We have developed a novel probe-based imaging and navigation system with high sensitivity for fluorescence detection, capability for fluorescence image reconstruction, multimodal image fusion and in situ PG display function. Our studies have demonstrated its clinical potential for intraoperative localization and in situ display of PGs in thyroidectomy or parathyroidectomy.
Topics: Optical Imaging; Parathyroid Glands; Parathyroidectomy; Surgery, Computer-Assisted; Thyroidectomy
PubMed: 35710423
DOI: 10.1186/s12938-022-01004-8 -
The Surgeon : Journal of the Royal... Jun 2021Symptomatic long-term hypoparathyroidism following thyroid surgery requires an alternative and permanent therapy that would effectively restore parathyroid function and... (Review)
Review
OBJECTIVE
Symptomatic long-term hypoparathyroidism following thyroid surgery requires an alternative and permanent therapy that would effectively restore parathyroid function and eliminate the need for substitution drug therapy. The aim of this study was to systematically review the literature on the efficacy and safety of parathyroid allotransplantation to treat post-operative hypoparathyroidism.
METHODS
MEDLINE, Embase, BIOSIS and the Cochrane Library were searched for published articles (from inception of each database to September 30, 2018). A total of 9 studies comprising 146 patients (177 allotransplantations) with post thyroidectomy hypoparathyroidism were identified.
RESULTS
Parathyroid tissues used for allotransplant were cultured parathyroid cells, cryopreserved parathyroid cells and encapsulated microspheres. Post-transplant immunosuppression was only reported in three studies, mainly with oral prednisolone for 2 weeks to 6 months. Mean graft survival following allotransplantation was 47% (95% CI 24%-71%) when patients were followed-up to 6 months and 41% (95% CI 2.3%-80%) at 12 months. There was significant unexplained heterogeneity observed between studies in both these groups (I > 50%). Parathyroid hormone (PTH) levels, and serum calcium levels post intervention was not reported in all studies, but available evidence suggests the levels remains higher (PTH level around 12 pg/ml; Ca level around 8 mg/dl) post-allotransplantation for up to 24 months.
CONCLUSIONS
Long-term benefit and harms of allotransplantation is still unclear due to the clinical and statistical heterogeneity observed among the studies. Therefore, conduct of a well-designed controlled clinical trial in the immediate future on allotransplantation is of paramount importance.
Topics: Humans; Hypocalcemia; Hypoparathyroidism; Parathyroid Glands; Parathyroid Hormone; Postoperative Complications; Thyroid Gland; Thyroidectomy
PubMed: 32680813
DOI: 10.1016/j.surge.2020.06.008 -
Surgery Oct 2022Intraoperative parathyroid gland identification can be challenging. Parathyroid glands have an intrinsic autofluorescence when excited by wavelengths in the...
BACKGROUND
Intraoperative parathyroid gland identification can be challenging. Parathyroid glands have an intrinsic autofluorescence when excited by wavelengths in the near-infrared region. Studies using near-infrared cameras to detect parathyroid gland near-infrared autofluorescence have suggested improved identification. The pathologic parathyroid glands in primary hyperparathyroidism have variable near-infrared autofluorescence intensity, but how this correlates with different characteristics of hyperparathyroidism is unknown. Our objective was to correlate the fluorescent intensity of excited glands with clinical variables to enhance a surgeon's ability to identify parathyroid glands.
METHODS
The data on patients undergoing surgery for primary hyperparathyroidism were collected. The images were collected intraoperatively with a handheld near-infrared device and analyzed. The data consisted of the ratio of mean parathyroid gland near-infrared autofluorescence over background (white gauze) near-infrared autofluorescence. The variables assessed for correlation with autofluorescence intensity were gland volume and weight, preoperative serum calcium and parathyroid hormone, age, body mass index, and sex. The images were quantified by Image J software (National Institutes of Health, Bethesda, MD). The lasso regression was analyzed by R version 4.1.3 to calculate adjusted P values (R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
From 2017 to 2021, 131 patients with primary hyperparathyroidism underwent parathyroidectomies of 151 parathyroid glands. The mean near-infrared autofluorescence intensity of parathyroid glands had a negative correlation with weight with lighter glands fluorescing more (P = .019) and a positive correlation with age with glands from older patients fluorescing more (P = .013). There were no significant correlations with preoperative serum calcium and parathyroid hormone, body mass index, and sex (P > .05).
CONCLUSION
In patients with primary hyperparathyroidism, we found that autofluorescence intensity correlated with parathyroid gland weight and patient age. This suggested that near-infrared camera use may be particularly helpful in identifying smaller adenomas and in older patients.
Topics: Aged; Calcium; Humans; Hyperparathyroidism, Primary; Optical Imaging; Parathyroid Glands; Parathyroid Hormone; Parathyroidectomy; Spectroscopy, Near-Infrared
PubMed: 35981919
DOI: 10.1016/j.surg.2022.06.027 -
Endocrine Practice : Official Journal... Jan 2022Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland...
Preoperative Calcium and Parathyroid Hormone Values Are Poor Predictors of Gland Volume and Multigland Disease in Primary Hyperparathyroidism: A Review of 2000 Consecutive Patients.
OBJECTIVE
Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration.
METHODS
Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H).
RESULTS
There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm, DA = 1.43 cm, and H = 1.27 cm; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001).
CONCLUSION
This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.
Topics: Calcium; Humans; Hyperparathyroidism, Primary; Parathyroid Glands; Parathyroid Hormone; Parathyroidectomy; Retrospective Studies
PubMed: 34403781
DOI: 10.1016/j.eprac.2021.08.003 -
JAMA Surgery Oct 2023Intraoperative identification of tissues through gross inspection during thyroid and parathyroid surgery is challenging yet essential for preserving healthy tissue and...
IMPORTANCE
Intraoperative identification of tissues through gross inspection during thyroid and parathyroid surgery is challenging yet essential for preserving healthy tissue and improving outcomes for patients.
OBJECTIVE
To evaluate the performance and clinical applicability of the MasSpec Pen (MSPen) technology for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively.
DESIGN, SETTING, AND PARTICIPANTS
In this diagnostic/prognostic study, the MSPen was used to analyze 184 fresh-frozen thyroid, parathyroid, and lymph node tissues in the laboratory and translated to the operating room to enable in vivo and ex vivo tissue analysis by endocrine surgeons in 102 patients undergoing thyroidectomy and parathyroidectomy procedures. This diagnostic study was conducted between August 2017 and March 2020. Fresh-frozen tissues were analyzed in a laboratory. Clinical analyses occurred in an operating room at an academic medical center. Of the analyses performed on 184 fresh-frozen tissues, 131 were included based on sufficient signal and postanalysis pathologic diagnosis. From clinical tests, 102 patients undergoing surgery were included. A total of 1015 intraoperative analyses were performed, with 269 analyses subject to statistical classification. Statistical classifiers for discriminating thyroid, parathyroid, and lymph node tissues were generated using training sets comprising both laboratory and intraoperative data and evaluated on an independent test set of intraoperative data. Data were analyzed from July to December 2022.
MAIN OUTCOMES AND MEASURES
Accuracy for each tissue type was measured for classification models discriminating thyroid, parathyroid, and lymph node tissues using MSPen data compared to gross analysis and final pathology results.
RESULTS
Of the 102 patients in the intraoperative study, 80 were female (78%) and the median (IQR) age was 52 (42-66) years. For discriminating thyroid and parathyroid tissues, an overall accuracy, defined as agreement with pathology, of 92.4% (95% CI, 87.7-95.4) was achieved using MSPen data, with 82.6% (95% CI, 76.5-87.4) accuracy achieved for the independent test set. For distinguishing thyroid from lymph node and parathyroid from lymph node, overall training set accuracies of 97.5% (95% CI, 92.8-99.1) and 96.1% (95% CI, 91.2-98.3), respectively, were achieved.
CONCLUSIONS AND RELEVANCE
In this study, the MSPen showed high performance for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively, suggesting this technology may be useful for providing near real-time feedback on tissue type to aid in surgical decision-making.
Topics: Humans; Female; Middle Aged; Aged; Male; Parathyroid Glands; Thyroid Gland; Parathyroidectomy; Thyroidectomy; Prognosis
PubMed: 37531134
DOI: 10.1001/jamasurg.2023.3229 -
Surgical Innovation Apr 2023The high-definition 3D exoscope is an innovative and promising tool that was recently introduced in the clinical practice. It may be used during open surgical procedures...
BACKGROUND
The high-definition 3D exoscope is an innovative and promising tool that was recently introduced in the clinical practice. It may be used during open surgical procedures to enhance the ability to perform precise dissection of fine structures. We describe our preliminary experience with the 3D exoscope in thyroid surgery, discussing potential advantages of this system.
METHODS
A high-definition 3D exoscope (3D VITOM) mounted on the VERSACRANE holding system (Karl Storz, Tuttlingen, Germany) was used to perform open thyroid surgery.
RESULTS
The 3D exoscope was used in three patients without significant intra-operative delay or complications. Both thyroidectomy and central compartment dissection were performed. The 3D exoscope allows to perform precise dissection in the identification and preservation of the recurrent laryngeal nerve and the parathyroid glands.
CONCLUSIONS
3D exoscope-assisted thyroid surgery seems to be feasible and safe. Further studies should be encouraged to analyze potential clinical benefit in the post-operative period.
Topics: Humans; Thyroid Gland; Parathyroid Glands; Thyroidectomy; Dissection; Germany
PubMed: 35533236
DOI: 10.1177/15533506221097553 -
The Laryngoscope Nov 2022To evaluate rates of incidental parathyroidectomy(IP) and to determine risk factors among children undergoing thyroid surgery.
OBJECTIVE
To evaluate rates of incidental parathyroidectomy(IP) and to determine risk factors among children undergoing thyroid surgery.
STUDY DESIGN
Retrospective case-control study.
METHODS
Pediatric patients undergoing thyroidectomy with or without neck dissection were included in this retrospective cohort study over a 20 year period. Demographics, clinical features, and surgical outcomes were evaluated. The primary outcome was the presence of parathyroid tissue in the surgical specimen.
RESULTS
Two hundred and eighty-six patients were included (100 cases with ≥1 parathyroid gland found in the pathology specimen and 186 controls). The most common surgical indication was cancer (49%), followed by benign nodule (25%). Hemithyroidectomy was performed in 119 (42%) patients, total thyroidectomy in 138 (48%), and completion in 29 (10%). Central neck dissection (CND) and lateral neck dissection were performed in 41% and 13%, respectively. 27 (9%) patients had parathyroid reimplantation. On univariable analysis, diagnosis, adenopathy on preoperative ultrasound, extent of thyroidectomy, neck dissection, and parathyroid reimplantation were significant predictors of IP. On multivariate analysis, CND > 5 nodes were the sole predictor of IP. Patients with IP were more likely to require postoperative calcium/vitamin D supplementation compared to those without (44% vs. 16%; P < .001).
CONCLUSIONS
Incidental parathyroidectomy during pediatric thyroidectomy is relatively common. CND was independently predictive of IP. There were increased rates of postoperative hypocalcemia when 1 or more parathyroid gland was identified in the specimen. Reimplantation of 1 parathyroid gland was predictive of another gland in the specimen. Anticipating outcomes may help optimize patient care by allowing for early supplementation, frequent monitoring, and consideration of ancillary monitoring modalities in high-risk procedures.
LEVEL OF EVIDENCE
Level 4 Laryngoscope, 132:2262-2269, 2022.
Topics: Calcium; Case-Control Studies; Child; Humans; Hypocalcemia; Neck Dissection; Parathyroid Glands; Parathyroidectomy; Retrospective Studies; Thyroid Gland; Thyroid Neoplasms; Thyroidectomy; Vitamin D
PubMed: 35191038
DOI: 10.1002/lary.30056 -
Frontiers in Endocrinology 2023Treatment options for thyroid pathologies have expanded to include scarless and remote access methods such as the transoral endoscopic thyroidectomy vestibular approach...
BACKGROUND
Treatment options for thyroid pathologies have expanded to include scarless and remote access methods such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Currently, no standardized methods exist for locating parathyroid glands (PGs) in patients undergoing TOETVA, which can lead to parathyroid injury and subsequent hypocalcemia. This early feasibility study describes and evaluates the hANDY-i endoscopic attachment for detecting PGs in transoral thyroidectomy.
METHODS
We used a prototype parathyroid autofluorescence imager (hANDY-i) that was mounted to a 10-mm 0-degree endoscope. The device delivers a split screen view of Red-green-blue (RGB) and near-infrared autofluorescence (NIRAF) which allows for simultaneous anatomical localization and fluorescence visualization of PGs during endoscopic thyroid dissection.
RESULTS
One cadaveric case and two patient cases were included in this study. The endoscopic hANDY-i imaging system successfully visualized PGs during all procedures.
CONCLUSION
The ability to leverage parathyroid autofluorescence during TOETVA may lead to improved PG localization and preservation. Further human studies are needed to assess its effect on postoperative hypocalcemia and hypoparathyroidism.
Topics: Humans; Thyroidectomy; Parathyroid Glands; Hypocalcemia; Endoscopy, Gastrointestinal; Thyroid Gland
PubMed: 37693365
DOI: 10.3389/fendo.2023.1233956 -
Journal of the College of Physicians... Apr 2021To determine the success rate of minimally invasive parathyroidectomies (MIPs) with preoperative scintigraphy and ultrasonography, and to assess whether these imaging... (Observational Study)
Observational Study
OBJECTIVE
To determine the success rate of minimally invasive parathyroidectomies (MIPs) with preoperative scintigraphy and ultrasonography, and to assess whether these imaging modalities are sufficient.
STUDY DESIGN
Observational study.
PLACE AND DURATION OF STUDY
Department of General Surgery, University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey between March 2017 and December 2019.
METHODOLOGY
Medical records of 61 patients, who underwent MIP to treat primary hyperparathyroidism, were examined. Age, gender, and pre- and postoperative calcium, parathormone, and phosphorus levels were obtained from patient records. For all patients, the parathyroid (PT) glands were localised, using ultrasonography and Tc-99m methoxyisobutylisonitrile (MIBI) scintigraphy.
RESULTS
The average patient age was 56.89 ± 13.47 years. Of the patients, 83.6% (n = 51) were females. Localisation of the PT glands with preoperative scintigraphy had an accuracy rate of 100%. However, ultrasonographic localisation was unsuccessful in five patients. Adenomas were noted in 44 patients (72.1%), hyperplasia in 15 patients (24.6%), and neoplasia in two patients (3.3%). Serum parathormone and calcium levels were measured 24 hours after surgery, and were found to be significantly reduced compared to the corresponding preoperative levels (p <0.001). Hypocalcaemia developed in four patients (6.6%), two (3.3%) of which were symptomatic. After three months, persistent hyperparathyroidism developed in five patients (8.2%).
CONCLUSION
Parathyroid scintigraphy has been demonstrated to be the gold standard for the preoperative localisation of PT glands. In the absence of scintigraphy, ultrasound guidance is the next useful technique for PT gland localisation. Key Words: Minimal invasive parathyroidectomy, Parathyroid scintigraphy, Ultrasonography, Parathormone.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Parathyroid Glands; Parathyroidectomy; Radiopharmaceuticals; Technetium Tc 99m Sestamibi; Turkey; Ultrasonography
PubMed: 33866731
DOI: 10.29271/jcpsp.2021.04.440