Global Cast MD, along with Cincinnati Children's
Hospital, sharing knowledge to improve child
health around the globe. Hello, Pediatric Surgery
family. I'm Em Gootee from Cincinnati Children's
Hospital Medical Center. In this video series,
we'll be recapping the sessions and sharing the
key highlights from our 12th annual update course
in Pediatric Surgery, which was held in August
2024. This year, we introduced a new approach
to classify practice -changing ideas in our update
course. Presentations now fall into three categories.
Green circles for established practices, blue
squares for promising newer practices, and black
diamond for early adopter practices only. Today,
we will review the use of autofluorescence and
ICG angiography for identifying parathyroid glands
and assessing their perfusion. Pediatric surgeons
Dr. Justin Huntington and Dr. Ben Hamb will be
guiding us through this session. This session
is classified as a black diamond for early adopter
practices only. We'll touch on both autofluorescence
and ICG angiography. Both of these things can
be used to help to identify the parathyroids,
but then also to assess their perfusion. Here's
one of the key considerations in thyroid surgery.
Preserving the parathyroid glands to reduce the
risk of hypocalcemia. and minimize the need for
calcium supplementation for both immediately
and long -term. So we want to start with this
poll. What has been shown to improve rates of
hypoparathyroidism or hypocalcemia after a thyroidectomy?
Looks like about a third said doing more than
25 surgeries, so high volume. What do you think,
Ben? Yeah, I certainly agree with A and... In
our group, I do all the thyroids. And even with
that, I don't do more than 25 a year. And so
I typically will invite one of the adult thyroid
surgeons who does do more than 25 a year to help
assist with identifying the parathyroids and
also the recurrent laryngeal nerve. According
to this randomized control trial from France,
using autofluorescence to identify parathyroid
glands may significantly reduce early postoperative
hypocalcemia. and improve parathyroid preservation
after total thyroidectomy. Parathyroids can auto
-fluoresce, so there's a fluo -beam system in
addition to the probe system, and they noted
hypocalcemia rates that were about half with
using it versus not using it. The need for auto
-transplantation is approximately one -third,
while the rate of resected parathyroid glands
in the specimen or otherwise is about a quarter.
And all those were significantly different in
the randomized controlled trial. Here, Dr. Huntington
shared important information regarding autofluorescence.
You don't inject anything. It's just the parathyroids
naturally autofluoresce at that wavelength. So
it's using that technology. And then in addition,
you can inject ICG to look at the perfusion of
the actual parathyroid. So this just shows an
example where you can see the thyroid gland lifted
and exposed. And then with the autofluorescence,
you can see the bright areas signifying the superior
and inferior parathyroids to help identify them
early and then be able to separate them from
the thyroid and work to preserve both them and
their blood supply. And then this is... adding
ICG. We have the flu optics machine and like
the pictures that are sort of published in the
studies like I haven't found it as nice as those
pictures but I do think it's a helpful adjunct.
So which of these things have been shown to correlate
with normal calcium after total thyroidectomy?
This study basically showed that there's no persistent
hypocalcemia if you see high fluorescence of
at least one parathyroid gland. Now exactly what
that means is kind of questionable because it's
somewhat subjective. It also gets tricky doing
it too because you can usually see two of them
at once and give the ICG and see if they perfuse.
Seeing both sides at once is a little tricky.
And we learned that the device itself is bulky
to use. So when should you consider parathyroid
re -implantation? I will say of all these things
with the flu optics machine, the one I find it
most useful for is looking at the specimen. And
we've definitely saved some parathyroid glands
that we may not have seen otherwise. The question
is, do we really need to reimplant parathyroid
glands in children? Risk of permanent parathyroidism
and hypocalcemia and the need for... What can
be very difficult to manage, hypocalcemia in
the setting of permanent severe hypoparathyroidism,
I think you've got to give them their best chance.
Here's one of the papers suggesting that emerging
imaging technologies, such as autofluorescence
and ICG angiography, hold promise for improving
gland identification and preservation. However,
their implementation varies, and research on
their effectiveness is still in the early stages.
I agree that the actual real -life use of it
may not be as good as advertised. It's helpful
to have the reps come do the first few to sort
of show you some of the tricks, especially when
you do the ICG, you have to change the sensitivity
pretty quickly or everything just lights up really
quickly and is not very useful. They did just
come out with a new one within the last month
where there's a switch you can flip to do autofluorescence
versus... ICG angiography so the ICG doesn't
overwhelm the autofluorescence. And I think the
technology will keep getting better and it will
become something that becomes more mainstream.
In summary, autofluorescence and ICG angiography
help identify parathyroid glands and assess perfusion,
reducing the risk of hypocalcemia after thyroid
surgery. Autofluorescence has shown reduced hypocalcemia
rates in trials. though real -life use can be
challenging due to device limitations. Emerging
technologies show promise for parathyroid preservation,
but face implementation challenges, especially
in lower volume centers. Thank you for watching.
Global Cast MD, along with Cincinnati Children's
Hospital, sharing knowledge to improve child
health around the globe.