Update Course Rewind: Autofluorescence & ICG Angiography in Thyroid Surgery 2024

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm M. Goldy 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 at 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 Ham, 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 uh 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 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 post-operative hypocalcemia and improve parathyroid preservation after total thyroidectomy. Parathyroids can autofluoresce, so there's a fluobeam system in addition to the probe system and they noted hypocalcemia rates that were about half uh with using 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 control 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 glands. So this just shows an example where you can see the thyroid gland lifted and exposed. And then with the autofluorescence, you can see uh 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. Um 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 um 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 reimplantation? 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 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 the the actual real life use of it may not be as good as, you know, advertised. It's helpful to have the reps, you know, 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 um ICG angiography. So the ICG doesn't overwhelm the autofluorescence. Yeah. And I think the technology will keep getting better and it will become something that becomes, you know, 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.