WEBVTT 00:00:00.970 --> 00:00:04.669 Global Cast MD, along with Cincinnati Children's 00:00:04.669 --> 00:00:06.830 Hospital, sharing knowledge to improve child 00:00:06.830 --> 00:00:09.990 health around the globe. Hello, Pediatric Surgery 00:00:09.990 --> 00:00:12.849 family. I'm Em Gootee from Cincinnati Children's 00:00:12.849 --> 00:00:15.730 Hospital Medical Center. In this video series, 00:00:15.970 --> 00:00:18.230 we'll be recapping the sessions and sharing the 00:00:18.230 --> 00:00:20.609 key highlights from our 12th annual update course 00:00:20.609 --> 00:00:23.109 in Pediatric Surgery, which was held in August 00:00:23.109 --> 00:00:26.129 2024. This year, we introduced a new approach 00:00:26.129 --> 00:00:28.850 to classify practice -changing ideas in our update 00:00:28.850 --> 00:00:32.320 course. Presentations now fall into three categories. 00:00:32.719 --> 00:00:35.479 Green circles for established practices, blue 00:00:35.479 --> 00:00:38.759 squares for promising newer practices, and black 00:00:38.759 --> 00:00:41.960 diamond for early adopter practices only. Today, 00:00:42.119 --> 00:00:44.659 we will review the use of autofluorescence and 00:00:44.659 --> 00:00:48.460 ICG angiography for identifying parathyroid glands 00:00:48.460 --> 00:00:52.340 and assessing their perfusion. Pediatric surgeons 00:00:52.340 --> 00:00:55.600 Dr. Justin Huntington and Dr. Ben Hamb will be 00:00:55.600 --> 00:00:58.259 guiding us through this session. This session 00:00:58.259 --> 00:01:01.539 is classified as a black diamond for early adopter 00:01:01.539 --> 00:01:04.939 practices only. We'll touch on both autofluorescence 00:01:04.939 --> 00:01:08.500 and ICG angiography. Both of these things can 00:01:08.500 --> 00:01:12.280 be used to help to identify the parathyroids, 00:01:12.280 --> 00:01:16.200 but then also to assess their perfusion. Here's 00:01:16.200 --> 00:01:18.400 one of the key considerations in thyroid surgery. 00:01:18.980 --> 00:01:21.519 Preserving the parathyroid glands to reduce the 00:01:21.519 --> 00:01:24.390 risk of hypocalcemia. and minimize the need for 00:01:24.390 --> 00:01:26.750 calcium supplementation for both immediately 00:01:26.750 --> 00:01:29.250 and long -term. So we want to start with this 00:01:29.250 --> 00:01:32.329 poll. What has been shown to improve rates of 00:01:32.329 --> 00:01:36.989 hypoparathyroidism or hypocalcemia after a thyroidectomy? 00:01:37.189 --> 00:01:39.250 Looks like about a third said doing more than 00:01:39.250 --> 00:01:42.349 25 surgeries, so high volume. What do you think, 00:01:42.349 --> 00:01:46.310 Ben? Yeah, I certainly agree with A and... In 00:01:46.310 --> 00:01:49.030 our group, I do all the thyroids. And even with 00:01:49.030 --> 00:01:52.109 that, I don't do more than 25 a year. And so 00:01:52.109 --> 00:01:55.329 I typically will invite one of the adult thyroid 00:01:55.329 --> 00:01:58.890 surgeons who does do more than 25 a year to help 00:01:58.890 --> 00:02:02.590 assist with identifying the parathyroids and 00:02:02.590 --> 00:02:05.230 also the recurrent laryngeal nerve. According 00:02:05.230 --> 00:02:07.469 to this randomized control trial from France, 00:02:07.769 --> 00:02:10.650 using autofluorescence to identify parathyroid 00:02:10.650 --> 00:02:13.990 glands may significantly reduce early postoperative 00:02:13.990 --> 00:02:17.599 hypocalcemia. and improve parathyroid preservation 00:02:17.599 --> 00:02:21.400 after total thyroidectomy. Parathyroids can auto 00:02:21.400 --> 00:02:24.840 -fluoresce, so there's a fluo -beam system in 00:02:24.840 --> 00:02:27.500 addition to the probe system, and they noted 00:02:27.500 --> 00:02:31.840 hypocalcemia rates that were about half with 00:02:31.840 --> 00:02:34.580 using it versus not using it. The need for auto 00:02:34.580 --> 00:02:37.039 -transplantation is approximately one -third, 00:02:37.219 --> 00:02:40.060 while the rate of resected parathyroid glands 00:02:40.060 --> 00:02:42.699 in the specimen or otherwise is about a quarter. 00:02:43.189 --> 00:02:45.770 And all those were significantly different in 00:02:45.770 --> 00:02:48.689 the randomized controlled trial. Here, Dr. Huntington 00:02:48.689 --> 00:02:51.710 shared important information regarding autofluorescence. 00:02:51.990 --> 00:02:54.669 You don't inject anything. It's just the parathyroids 00:02:54.669 --> 00:02:57.830 naturally autofluoresce at that wavelength. So 00:02:57.830 --> 00:03:00.610 it's using that technology. And then in addition, 00:03:00.770 --> 00:03:03.889 you can inject ICG to look at the perfusion of 00:03:03.889 --> 00:03:07.889 the actual parathyroid. So this just shows an 00:03:07.889 --> 00:03:10.610 example where you can see the thyroid gland lifted 00:03:10.610 --> 00:03:13.849 and exposed. And then with the autofluorescence, 00:03:13.849 --> 00:03:17.990 you can see the bright areas signifying the superior 00:03:17.990 --> 00:03:21.069 and inferior parathyroids to help identify them 00:03:21.069 --> 00:03:23.669 early and then be able to separate them from 00:03:23.669 --> 00:03:26.710 the thyroid and work to preserve both them and 00:03:26.710 --> 00:03:29.449 their blood supply. And then this is... adding 00:03:29.449 --> 00:03:34.370 ICG. We have the flu optics machine and like 00:03:34.370 --> 00:03:37.310 the pictures that are sort of published in the 00:03:37.310 --> 00:03:41.729 studies like I haven't found it as nice as those 00:03:41.729 --> 00:03:45.650 pictures but I do think it's a helpful adjunct. 00:03:45.830 --> 00:03:48.569 So which of these things have been shown to correlate 00:03:48.569 --> 00:03:51.310 with normal calcium after total thyroidectomy? 00:03:51.550 --> 00:03:54.870 This study basically showed that there's no persistent 00:03:54.870 --> 00:03:59.669 hypocalcemia if you see high fluorescence of 00:03:59.669 --> 00:04:02.550 at least one parathyroid gland. Now exactly what 00:04:02.550 --> 00:04:05.490 that means is kind of questionable because it's 00:04:05.490 --> 00:04:08.289 somewhat subjective. It also gets tricky doing 00:04:08.289 --> 00:04:10.750 it too because you can usually see two of them 00:04:10.750 --> 00:04:13.490 at once and give the ICG and see if they perfuse. 00:04:13.490 --> 00:04:15.990 Seeing both sides at once is a little tricky. 00:04:16.430 --> 00:04:19.209 And we learned that the device itself is bulky 00:04:19.209 --> 00:04:22.910 to use. So when should you consider parathyroid 00:04:22.910 --> 00:04:26.220 re -implantation? I will say of all these things 00:04:26.220 --> 00:04:29.160 with the flu optics machine, the one I find it 00:04:29.160 --> 00:04:32.040 most useful for is looking at the specimen. And 00:04:32.040 --> 00:04:34.480 we've definitely saved some parathyroid glands 00:04:34.480 --> 00:04:37.220 that we may not have seen otherwise. The question 00:04:37.220 --> 00:04:40.199 is, do we really need to reimplant parathyroid 00:04:40.199 --> 00:04:43.120 glands in children? Risk of permanent parathyroidism 00:04:43.120 --> 00:04:46.639 and hypocalcemia and the need for... What can 00:04:46.639 --> 00:04:49.579 be very difficult to manage, hypocalcemia in 00:04:49.579 --> 00:04:53.139 the setting of permanent severe hypoparathyroidism, 00:04:53.180 --> 00:04:55.879 I think you've got to give them their best chance. 00:04:56.160 --> 00:04:58.579 Here's one of the papers suggesting that emerging 00:04:58.579 --> 00:05:01.759 imaging technologies, such as autofluorescence 00:05:01.759 --> 00:05:05.040 and ICG angiography, hold promise for improving 00:05:05.040 --> 00:05:08.240 gland identification and preservation. However, 00:05:08.560 --> 00:05:11.480 their implementation varies, and research on 00:05:11.480 --> 00:05:13.959 their effectiveness is still in the early stages. 00:05:14.720 --> 00:05:18.600 I agree that the actual real -life use of it 00:05:18.600 --> 00:05:21.680 may not be as good as advertised. It's helpful 00:05:21.680 --> 00:05:25.000 to have the reps come do the first few to sort 00:05:25.000 --> 00:05:26.759 of show you some of the tricks, especially when 00:05:26.759 --> 00:05:29.699 you do the ICG, you have to change the sensitivity 00:05:29.699 --> 00:05:32.540 pretty quickly or everything just lights up really 00:05:32.540 --> 00:05:35.360 quickly and is not very useful. They did just 00:05:35.360 --> 00:05:37.920 come out with a new one within the last month 00:05:37.920 --> 00:05:42.139 where there's a switch you can flip to do autofluorescence 00:05:42.139 --> 00:05:46.990 versus... ICG angiography so the ICG doesn't 00:05:46.990 --> 00:05:49.230 overwhelm the autofluorescence. And I think the 00:05:49.230 --> 00:05:51.870 technology will keep getting better and it will 00:05:51.870 --> 00:05:55.709 become something that becomes more mainstream. 00:05:56.430 --> 00:05:59.350 In summary, autofluorescence and ICG angiography 00:05:59.350 --> 00:06:02.889 help identify parathyroid glands and assess perfusion, 00:06:03.009 --> 00:06:06.329 reducing the risk of hypocalcemia after thyroid 00:06:06.329 --> 00:06:10.470 surgery. Autofluorescence has shown reduced hypocalcemia 00:06:10.470 --> 00:06:13.579 rates in trials. though real -life use can be 00:06:13.579 --> 00:06:16.839 challenging due to device limitations. Emerging 00:06:16.839 --> 00:06:19.680 technologies show promise for parathyroid preservation, 00:06:20.060 --> 00:06:23.040 but face implementation challenges, especially 00:06:23.040 --> 00:06:26.639 in lower volume centers. Thank you for watching. 00:06:28.240 --> 00:06:32.160 Global Cast MD, along with Cincinnati Children's 00:06:32.160 --> 00:06:34.300 Hospital, sharing knowledge to improve child 00:06:34.300 --> 00:06:35.319 health around the globe.