2024 Update Course - Enlarging the Scope of ICG: Thyroid Use - P. Ben Ham & Justin Huntington

All right, we're gonna move on. We are staying relatively close to time, uh, ish-ish. All right, um, so the next topic is on ICG and its use in thyroid disease, and we got Justin again. I don't know how he made it up here to stage twice. Well, I know the first one was gonna be Mark Walk. I know Mark, Mark, Mark Wolan is getting married in a few days, and, uh, he's, uh, what kind of excuse is that? Kind of, kind of disappointing Justin. Uh, but we're going to talk about ICG and you want me to, we're going to show the, uh, The, the, the rating score, yeah. So, yeah, go ahead, Ben. Hi, I'm Ben Hamm, one of the pediatric surgeons at Oshi Children's Hospital. Justin I'm at Akron. And we were initially asked to talk about ICG, but in doing, uh, some research in the literature about it, we also noticed, uh, some other groups have reported something a little different, so we chose to include it as well. And so we'll touch on, uh, both autofluorescence and ICG and geography. Next slide. Um, and so both of these things can be used to help to identify the parathyroids, but then also, uh, to assess their profusion. And so, uh, one of the things we think about in thyroid surgery is we want to preserve the parathyroids and decrease the risk of hypocalcemia and the need for calcium supplementation, uh, both initially and over a long period of time. Um, and so these are some adjuncts that we can use to try to help with that. So we want to start with this pool. Uh, what has been shown to improve rates of hypoparathyroidism or hypocalcemia after thyroidectomy? Can we see how many people do thyroid surgery in the room? 231234 including us 56 yeah maybe yeah so not a, not a lot, um, did have you heard of this technology at all if you do, I'm saying yes yes who's the third person. There were 2 over here, OK. And do you guys use, do you use anything? all It works very well. I used the outer fluorescence and it was the worst hypocalcemia we ever had on a patient. And we don't usually have bad hypocalcemia. If we have it, it's mostly transient and was resolved with oral calcium supplementation and goes away over time. So I almost wondered if we got fooled into not just using the things that we normally do to identify the parathyroid glands. Did you use the autofluorescence probe or the autofluorescence video mechanism? Do you know which probe? OK, probe. OK. Anybody use any of the other technology? Wanna comment? OK. Well, when we see what people are saying. It's kind of hard to read, um, really split. So Looks like about 1/3 said doing more than 25 surgeries, so high volume. A third said A plus C, which was ICG and 25. Yeah, what do you think, Ben? Yeah, I, I certainly agree with A and even, um, in our group, we have 5 pediatric surgeons, and so 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. Um, and then, In the literature, uh, the autofluorescence, um, has been shown to decrease rates in a randomized controlled trial out of France. And so, uh, transient rates, um, are 15 to 30%. Uh, permanent rates, uh, have been reported even up to 15%. Um, there's a greater concern for those in pediatric patients. And so identification of the parathyroids and also preservation of their blood supply. Auto transplantation, if it's at risk and help to decrease those rates. Next slide. Well, let's keep going. Next slide. And so, um, I mentioned the randomized control trial, but I'll, I'll talk about, uh, what was done. And so parathyroids can autofluoresce. So, um, there's a, a technology system, uh, the fluoeam system, um, in addition to the probe system and with using the fluoeam system, They noted hypocalcemia rates that were about 50%, uh, with using it versus not using it. Uh, the need for auto-transplantation, uh, about 1/3, and then the rate of resected parathyroids in the specimen or otherwise was about 25%, and all those were significantly different in the randomized control trial. And then I'll just point out the autofluorescence that works with nothing. You don't inject anything. It's just the parathyroids naturally autofluoresce at that wavelength. So it's using that, um, technology. And then in addition, you can inject ICG and we'll get to that later to look at the profusion of the actual, um, parathyroid glands. Uh, so this just shows, um, an example where, um, 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 and we'll kind of get into some of those indications. I will agree, like 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 for a few things that we'll get to. All right. Um, I think this is me. So, um, which of these things have been shown to correlate with normal calcium, um, after total thyroidectomy? PTH greater than 20 PTH less than 20? Um, high fluorescence intensity of at least one parathyroid gland. Um, or DEA plus C. I think our like questions are really easy, but we'll see what people say. Why don't we just for the sake of time, yeah, let's go, go to the next one the poll and see how many have answered and then looks like at least the majority are saying A and C. Yeah, so let's keep going, um, so 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, you know, is kind of questionable because it's somewhat subjective, I guess I would say, um, let's go to the next one. It also gets tricky doing it too, cause 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. Um, and the, the device itself is kind of bulky, uh, to use. Um, so when should you consider parathyroid reimplantation? A, ICG shows poor vascularity. Uh, B, um, autofluorescence shows parathyroid on the thyroid specimen. See what's reimplantation. So I guess all but 4 people in the room will pick that. And then, uh, D is A and B. Let's go to the next one. And see the pole. And I will say of all these things with the, uh, with the flu optics machine, the one I find it most useful for is looking at the specimen. And, and you, we've definitely, you know, saved some parathyroid glands that we may not have seen otherwise. Um, all right, it looks like, yes, most people are saying A and Bred. All right, uh, next. Um, and this just talks about reimplantation. Um, we can go to the next slide. Plant in children OK, the question is, do we really need to reimplant in children? Let me think. If you're talking about the risk of permanent hypoparathyroidism 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, I guess you can. I would kind of ask another question. Do you mean if you see it and it doesn't perfuse well, or you see it like on the specimen? Well, I would suggest I think both of those things don't work very well. So the autofluorescence and the ICG I don't think work very well for identifying the parathyroid. And so we don't use that. Um, and if we do happen to see a parathyroid that maybe looks like it doesn't have the best blood supply, we just stuff it. Back where we found it. And I think it gets blood supply from the surrounding tissue. So my question is, do you really need to put it somewhere else, or can you just leave it where it is? And is that different in children and adults, maybe considering children have a better propensity to revascularize the parathyroid. Yeah, I think that's a good point. That's a good question. Um, something to think about. We'll keep moving, um. Because we, we've got 2 minutes, um. And then, um, what's, you wanna do the conclusions and we can, sure. So there are a few papers out there suggesting that some emerging imaging technologies using autofluorescence and ICG angiography do hold promise to help improve identification and preservation, uh, of the glands. Uh, they can be difficult to implement and there are varying. Uh, we mentioned the probe, the actual video, uh, ICG versus autofluorescence, and so all of these are just beginning to be studied. And, um, another question becomes, how do you get your center to, if, if it is indeed, uh, as beneficial as shown in the randomized controlled trial, when you may do 10 or less than 25 per year. Um, how as a pediatric center do we advocate for our patients to have these things that at least are starting to be shown in adult trials to hold promise? Yeah, I think those are good points. I, I will say, um, you can go to the next slide. I think it shows sort of the, um, keep going. Keep going. Yeah, the, um, I mean, I agree that the actual real-life use of it may not be as good as, you know, advertised. Um, 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. Um, 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, and I think the technology will keep getting better and it will become something that becomes. You know, more mainstream, and then I, I think the other, you, I think you made a good point, like, you know, make use of the adult endocrine surgeons, um, limit the number of surgeons who do these, and like we have a great group for the, um, for thyroid surgery where we have an IR person, a pathologist, radiologist, endocrinologist, we meet monthly, um, an ENT and surgeon. It's super helpful to do that, and I think if of anything that probably improves outcomes more than anything else. Thank you guys. This was awesome. And you know, the, the, um, so let's hear it for these guys. That was awesome. Thank you.