Parathyroid Protection Research Articles

A Miniaturized Endoscopic Device Integrating Raman Spectroscopy and Laser Speckle Technology Via an Image Fusion Algorithm for Intraoperative Identification and Functional Protection of Parathyroid Glands

Abstract The importance of parathyroid glands (PGs) protection is increasingly recognized by thyroid surgeons in the field of minimally invasive video-assisted thyroidectomy (MIVAT). However, current techniques for intra-operative identification and vascularity assessment of the PGs are contentious and complex. This study presents the design and validation of a miniaturized device for fusion near-infrared autofluorescence (NIRAF) based on Raman spectroscopy and laser speckle contrast imaging (LSCI) via an image fusion algorithm for functional protection of PGs in the MIVAT. Our light source components include an integrated light emitting diode (LED) light source fiber, an NIRAF optical fiber, an acquisition optical fiber, and a laser speckle optical fiber in the endoscopic system to achieve identification and vascularity assessment of PGs using a single endoscopic probe. It has been validated in ex vivo tissue experiments that the fluorescence intensity detected by the device was equivalent to that of the marker indocyanine green (ICG) in visual images and superior to that of the thyroid and all other tissues in the neck. Based on clinical studies, MIVAT using functional fluorescence endoscopy, compared with the White light pattern group, the NIRAF combined with LSCI modality group increased the number of intra-operative confirmations of the PGs (P < 0.001), declined the decrease in parathyroid hormone (PTH) (P < 0.05) and calcium levels (P < 0.05) on the first postoperative day, and reduced the incidence of symptomatic hypocalcemia (P < 0.05). Our device may reduce the incidence of postoperative permanent hypoparathyroidism. Application of an miniaturized functional fluorescence endoscope for real-time and label-free PGs identification and vascularity assessment in MIVAT could be realized.

Intraoperative strategies in identification and functional protection of parathyroid glands for patients with thyroidectomy: a systematic review and network meta-analysis.

This study aimed to assess the benefits and limitations of four intraoperative visualization of parathyroid gland (IVPG) strategies in the identification and functional protection of parathyroid glands (PGs). We searched PubMed, the Cochrane Central Register of Controlled Trials, CNKI, EMBASE, Web of Science and Google Scholar databases until 30 June 2023. Four IVPG strategies were composed of the naked eyes (NE) and three imaging strategies: autofluorescence (AF), indocyanine green fluorescence (ICGF), and carbon nanoparticles (CN). We performed a pairwise meta-analysis (PMA) for direct comparisons and a Bayesian network meta-analysis (NMA) for indirect comparisons. A total of 29 eligible studies were included. According to NMA and PMA, AF had significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, PG inadvertent resection, and PG auto-transplantation compared to NE, while had significantly higher rate of PG identification. CN showed significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, and PG inadvertent resection compared to NE in PMA and NMA. ICGF showed a significantly higher rate of PG auto-transplantation compared to NE in PMA and AF in NMA. According to SUCRA values, AF showed the best advantage in reducing the rate of postoperative hypocalcemia (0.85) and PG inadvertent resection (0.89), and increasing the rate of PG identification (0.80). CN had the greatest advantage in reducing the rate of postoperative hypoparathyroidism (0.95). ICGF ranked the highest in the rate of PG auto-transplantation (0.98). Three imaging strategies demonstrate significant superiority over NE in the intraoperative PG identification and functional protection. AF is the best strategy in reducing the incidence of postoperative hypocalcemia, increasing the rate of PG identification, and reducing the rate of PG inadvertent resection and auto-transplantation. ICGF has great value in assessing PG viability, leading to the trend towards PG auto-transplantation. CN is the best strategy in reducing the incidence of postoperative hypoparathyroidism.

Effect of intraoperative active exploration of parathyroid glands to reduce the incidence of postoperative hypoparathyroidism, and risk factors of hypoparathyroidism after total thyroidectomy: a single-center study.

The risk factors for hypoparathyroidism after thyroid surgery have not been fully identified. This study analyzes the risk factors of hypoparathyroidism before and after total thyroidectomy. We retrospectively collected the clinical data of 289 patients who underwent total thyroidectomy at the Thyroid Surgery Center of Lishui Central Hospital from June 2018 to June 2020. For the anatomy and protection of parathyroid glands during the operation, one group of patients used the parathyroid avoidance method, and the other group used the active exploration method. Various risk factors affecting parathyroid dysfunction were studied using logistic regression models. A total of 289 patients were included in this study. The average age of patients was 47.21 ± 11.78 years, including 57 males (19.7%) and 232 females (80.3%). There were 149 (51.6%) patients with transient hypoparathyroidism and 21 (7.3%) with permanent hypoparathyroidism. The main risk factors of hypoparathyroidism were parathyroid avoidance method (P = 0.005), parathyroid autotransplantation (P = 0.011), bilateral central neck lymph node dissection (CND) (P = 0.001), lymphatic metastasis (P = 0.039), and parathyroid in the specimen (P = 0.029). The main risk factors associated with permanent hypoparathyroidism were bilateral CND (P = 0.038), lymphatic metastasis (P = 0.047), parathyroid hormone (PTH) < 1.2 pg/ml within three days after surgery (P = 0.006). Hypoparathyroidism is common but mostly transient after bilateral total thyroidectomy. Compared with parathyroid avoidance method, the active exploration method during operation may reduce the incidence of postoperative hypoparathyroidism. PTH <1.2 pg/ml within three days after surgery was predictive in patients with permanent hypoparathyroidism.

Clinical feasibility of imaging with indocyanine green combined with methylene blue for sentinel lymph node identification in papillary thyroid microcarcinoma

Objective:To explore the value of indocyanine green（ICG） combined with methylene blue in the identification of sentinel lymph nodes（SLNs） in patients diagnosed with papillary thyroid microcarcinoma（PTMC）. Methods:Ninety patients were enrolled and were randomized into group A and group B with 45 patients in each group. ICG combined with methylene blue were injected into the thyroid in group A, and only methylene blue were injected into thyroid in group B. Blue-stained or fluorescent nodes observed using near-infrared fluorescence imaging systems were defined as SLNs. After SLNs were removed, central lymph nodes（CLNs） dissection was completed in both groups. The pathological data and postoperative outcomes were compared between two groups. Results:There were significantly more SLNs（2.93/2.17） and CLNs（4.51/3.89） were dissected in group A than in group B（P<0.05）. There were no significant differences in sensitivity, accuracy and the false-negative rate according the SLNs in two groups（P>0.05）, but group A has higher sensitivity and accuracy rates, and lower false-negative rate. There were no significant differences in the amount of blood loss, the amount of lymphatic drainage, and incidence of hoarseness and lymphatic leakage in two groups（P>0.05）. In group A, the operating time was longer, and the rate of hypoparathyroidism was lower（P<0.05）. Conclusion:Sentinel lymph nodes biopsy using ICG combined with methylene blue is feasible and safe for SLNs identification in PTMC patients. It is also clinically significant for the parathyroid gland protection.

The role of carbon nanoparticle in lymph node detection and parathyroid gland protection during thyroidectomy for non-anaplastic thyroid carcinoma- a meta-analysis.

To assess the efficiency of the carbon nanoparticles (CNs) in lymph node identification and parathyroid gland (PG) protection during thyroidectomy for non-anaplastic thyroid carcinoma (N-ATC). A systematic literature search for relevant literatures published up to December 2018 in PubMed, EMBASE, Web of Science and Cochrane Library was performed. Both English and Chinese literatures were retrieved and analyzed. Randomized controlled trials or nonrandomized controlled trials comparing the use of CNs with the use of methylene blue or a blank control in patients undergoing thyroidectomy for N-ATC were enrolled in this study. The primary outcomes included the number of lymph nodes harvested, the rate of lymph nodes involved, and the rates of accidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Weighted mean differences (WMDs), odds ratios (ORs) and risk differences (RDs) were calculated for the dichotomous outcome variables. Between study heterogeneity was tested using the Q tests and the I2 statistics. All analyses were performed using Review Manager (version 5.3.5). 25 studies comprising 3266 patients were included in this analysis. The total number of lymph nodes harvested in the CNs groups was significantly higher than that in the control groups (WMD, 2.36; 95% CI, 1.40 to 3.32; P <0.01). Administrating CNs was associated with a lower incidence of accidental PG removal (OR = 0.28, 95% CI = 0.21 to 0.37, P<0.01) and lower rates of both postoperative transient hypoparathyroidism (OR = 0.46, 95% CI = 0.33 to 0.64, P <0.01) and transient hypocalcemia (OR = 0.46, 95% CI = 0.33 to 0.65, P <0.01). No significant difference was found concerning lymph node metastatic rates between CNs group and control group. Subgroup analysis indicated that the application of CNs in reoperation thyroidectomy reduced both the rate of transient hypoparathyroidism (OR = 0.21, 95% CI = 0.06 to 0.75, P = 0.02) and the possibility of accidental PGs removal (OR = 0.21, 95% CI = 0.07 to 0.62, P = 0.004, P<0.05). The application of CNs in thyroidectomy for N-ATC results in higher number of lymph node harvested and better PG protection during both initial and reoperation thyroidectomy.

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

BackgroundParathyroid 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.MethodsA 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.ResultsThere 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.ConclusionsCarbon 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.

Application of Nanocarbon in Breast Approach Endoscopic Thyroidectomy Thyroid Cancer Surgery.

Objective: This study aimed to investigate the application of nanocarbon in surgical endoscopy in patients with thyroid cancer for the clinical tracing of level VI sentinel lymph nodes (SLNs) and for parathyroid gland protection. Materials and Methods: Ninety-three patients with papillary thyroid carcinoma (PTC) who underwent an endoscopic thyroid cancer operation were included. We randomly divided these patients into a control group (n = 42) and a nanocarbon group (n = 51). For the nanocarbon group, after thyroid exposure, nanocarbon was injected into the thyroid gland, and the SLNs were resected and subjected to frozen sectioning and routine pathological examination. In addition, the postoperative calcium and parathyroid hormone (PTH) levels of both groups were analyzed to compare the features of the nanocarbon application. Results: The number of central lymph (level VI) nodes dissected and the number of metastatic lymph nodes identified were analyzed in both groups. The number of dissected lymph nodes from both unilateral and bilateral thyroid surgeries was significantly larger in the nanocarbon group than in the control group. At the same time, the number of identified metastasis lymph nodes dissected were higher in the nanocarbon group than in the control group. We assessed the postoperative calcium and PTH level to evaluate the parathyroid function. Our results show that the nanocarbon group had a better protective effect on parathyroid function than the control group. Conclusions: As a lymph node trace agent, nanocarbon could better evaluate and permit a more clear lymph dissection for patients with PTC. Nanocarbon contributes to a decrease in the incidence rate of parathyroid damage, which has great clinical value.

Clinical feasibility of imaging with indocyanine green combined with carbon nanoparticles for sentinel lymph node identification in papillary thyroid microcarcinoma

Background:Although several previous studies demonstrated the feasibility and efficacy of indocyanine green (ICG) for thyroid cancer surgery, ICG was administered through venous injection and focused on parathyroid gland protection. We thus aimed to study the feasibility of imaging using ICG combined with carbon nanoparticles (CNs) in the identification of sentinel lymph nodes (SLNs) in patients diagnosed with papillary thyroid microcarcinoma (PTMC).Methods:Two approaches were applied to detect lymph nodes in PTMC surgery. Patients were randomized into 2 groups. ICG and CNs were injected into the thyroid in Group A. In Group B, only CNs was injected. Black-stained or fluorescent nodes observed using near-infrared fluorescence imaging systems were defined as SLNs. SLN and central lymph node (CLN) dissection was completed in both groups. The pathological and postoperative outcomes were compared between 2 groups.Results:There were 40 patients in Group A and 60 in Group B. A total of 138 SLNs were identified; 72 and 66 SLNs were detected and dissected in Groups A and B, respectively. The number of SLNs identified (per patient) in Group A was higher than that in Group B (P = .027). The number of harvested CLNs was 161 and 192 in Groups A and B, respectively, out of which 45 and 48 lymph nodes with metastasis were confirmed by permanent pathology. The CLN metastatic rate in Group A was higher than that in Group B (P = .048).Conclusion:Imaging using ICG combined CNs is feasible and safe for SLN identification in PTMC patients. Compared with using only CNs, more SLNs can be removed and more metastatic lymph nodes can be confirmed when using the combined method. Although the combined method appears to accurately stage tumors, further research is needed.

Progress in identification and protection of parathyroid gland during thyroidectomy

Thyroid cancer is a common head and neck malignant tumor, it has become a malignant tumor of the highest incidence in young women in China. The treatment of thyroid cancer is a surgery-based comprehensive therapy, and the protection of the parathyroid gland during surgery has always been a major problem for clinicians. The methods for protection of parathyroid glands are in situ preservation or immediate parathyroid autotransplantation according to whether or not the blood supply can be maintained. To identify the parathyroid gland is the key issue of the protection during thryoidectomy. This article reviews the recent progress of the identification and protection of parathyroid glands at home and abroad. Key words: Parathyroid glands; Parathyroid protection; Surgical procedures, operative, thyroid gland

Potential role of carbon nanoparticles in protection of parathyroid glands in patients with papillary thyroid cancer.

As a novel type of lymphatic tracer, carbon nanoparticles (CNs) were reported not to stain parathyroid glands (PGs) into black, so it may have a clinical potential in protection of PGs during thyroidectomy. The purpose of this study was to investigate the clinical application and significance of CN in protection of PGs from surrounding tissues.A total of 82 consecutive patients were enrolled into this study and were divided into CN group and control group. Parathyroid function (hypoparathyroidism and hypocalcemia) was evaluated.The identification rates of PGs (≤2) and PGs (≥3) were 24.4% and 75.6% in the CN group and 46.3% and 53.7% in the control group, respectively. The difference in the identification rates between the 2 groups was statistically significant (P = 0.038). Pathological results revealed 3 accidental PGs resection occurred in the CN group, whereas 9 accidental PGs removal occurred in the control group. The difference was statistically significant (P = 0.046). Moreover, the incidence of the patients with hypoparathyroidism was statistically significant between the 2 groups (36.6% in CN group vs 53.7% in control group, P = 0.043) at day 1, but not at day 7 (P = 0.424).CN may have a potential in protecting PGs clinically.

Parathyroid protection in surgery of bilateral papillary thyroid cancer

To evaluate the protection of parathyroid glands in bilateral papillary thyroid cancer patients who underwent total thyroidectomy and bilateral central compartment dissection. The clinical data of 78 patients undergoing total thyroidectomy and bilateral central compartment dissection between May 2013 and May 2014 were analyzed retrospectively. Among 78 patients, 131 superior parathyroid glands were protected in situ, among those, 112 parathyroid glands located at the level of inferior edge of parathyroid cartilage; 19 parathyroid glands located in the superior 1/3 part of the back sides of the thyroid glands. All the superior parathyroid glands located in the superior and lateral-superior part of the 2 cm part down from the entrance of recurrent laryngeal nerve. A total of 110 inferior parathyroid glands were protected in situ, among those, 57 glands located in the superior of inferior thyroid artery; 24 glands located just on the surface of inferior thyroid artery; 29 glands located below the superior of inferior thyroid artery. Three parathyroid glands were found in the dissected tissues and were implanted immediately. Seven parathyroid glands were found with post-operative pathologic examinations. During surgery, four parathyroid glands was found in 27 patients, three in 30 patients, two in 16 patients, and one in 5 patients. For papillary thyroid cancer patients who underwent total thyroidectomy and bilateral central compartment dissection, identification of parathyroid glands and protection of blood supply to glands are the most effective methods to prevent hypoparathyroidism.

Application of nano-carbon in lymph node dissection for thyroid cancer and protection of parathyroid glands.

BackgroundThe aim of this study was to explore a new method to identify and protect parathyroid glands in neck lymph node dissection for patients with thyroid cancer.Material/MethodsOne hundred patients with thyroid cancer underwent total thyroidectomy combined with central neck lymph node dissection. During the operation, 50 patients receiving nano-carbon suspension were included in the experiment group, and 50 patients without nano-carbon suspension were included in the control group. We compared changes in parathyroid hormone levels before surgery and at 48 h after surgery between the 2 groups and of serum Ca2+ level within 48 h after surgery, as well as postoperative parathyroid pathological and lymph node dissection results.ResultsEight and 1 parathyroid glands were detected pathologically in the control and experimental group, respectively. Decrease in parathyroid hormone level at 48 h occurred in 7 patients in the control group and 1 patient in the experimental group. Hypocalcemia was found at 48 h after surgery in 10 patients in the control group and 2 patients in the experimental group.ConclusionsNano-carbon suspension can cause development of the thyroid gland and the central lymph node and a negative development of parathyroid glands. Careful identification and removal of black-stained lymphatic tissues in the process of total thyroidectomy with neck lymph node dissection can ensure a complete lymph node dissection and prevent parathyroid damage, thus effectively reducing the incidence of hypoparathyroidism.