In vivo fluorescence imaging: success in preclinical imaging paves the way for clinical applications.

Advances in diagnostic imaging have provided unprecedented opportunities to detect diseases at early stages and with high reliability. Diagnostic imaging is also crucial to monitoring the progress or remission of disease and thus is often the central basis of therapeutic decision-making. Currently, several diagnostic imaging modalities (computed tomography, magnetic resonance imaging, and positron emission tomography, among others) are routinely used in clinics and present their own advantages and limitations. In vivo near-infrared (NIR) fluorescence imaging has recently emerged as an attractive imaging modality combining low cost, high sensitivity, and relative safety. As a preclinical tool, it can be used to investigate disease mechanisms and for testing novel diagnostics and therapeutics prior to their clinical use. However, the limited depth of tissue penetration is a major challenge to efficient clinical use. Therefore, the current clinical use of fluorescence imaging is limited to a few applications such as image-guided surgery on tumors and retinal angiography, using FDA-approved dyes. Progress in fluorophore development and NIR imaging technologies holds promise to extend their clinical application to oncology, cardiovascular diseases, plastic surgery, and brain imaging, among others. Nanotechnology is expected to revolutionize diagnostic in vivo fluorescence imaging through targeted delivery of NIR fluorescent probes using antibody conjugation. In this review, we discuss the latest advances in in vivo fluorescence imaging technologies, NIR fluorescent probes, and current and future clinical applications.

Robotic-assisted parathyroidectomy via transaxillary approach: feasibility and learning curves.

BACKGROUND: There have been few reports of robotic-assisted transaxillary parathyroidectomy in the literature. We aim to report our experience with robotic-assisted transaxillary parathyroidectomy for primary hyperparathyroidism (PHPT) in the Western population. METHODS: A retrospective study was performed from July 2010 through July 2019 at two institutions, one in the United States and one in France. Demographic characteristics and perioperative data were collected for all patients undergoing robotic-assisted transaxillary parathyroidectomy by a single surgeon at each institution. A linear regression model was developed to describe the learning curve for this procedure at each institution. RESULTS: One-hundred and two patients with PHPT were included with a median age of 55.6±12.4 years and median body mass index (BMI) of 25.5±6.1 kg/m2. The majority of patients were female (80.4%). Median total operative time was 116±53 minutes. Minor complications were reported in 2 patients (1.96%), and one case was converted to a trans-cervical approach (TCA) for four-gland exploration. Median patient follow-up time was 6.5±12.2 months, and disease recurrence was reported in one patient. Calculated learning curves showed that one surgeon achieved proficiency by the eighth case, and the other achieved proficiency by the fourteenth case. CONCLUSIONS: This is the largest reported experience of robotic-assisted transaxillary parathyroidectomy for PHPT in the Asian and Western population. Analysis of the procedural learning curve demonstrates that proficiency in this technique was achieved after performance of less than 15 surgeries. This procedure is safe and feasible in the hands of experienced surgeons for select patients with localized disease.

Surgery for Graves' disease in the era of robotic-assisted surgery: a study of safety and feasibility in the Western population.

PURPOSE: Thyroid surgery for Graves' disease is known to be associated with higher risk of complications. We seek to compare outcomes between robotic-assisted and open cervical approach thyroid surgery in patients with Graves' disease in the Western population. METHODS: We performed a retrospective cohort study using prospectively collected databases for patients undergoing robotic-assisted or conventional cervical approach thyroid surgery for Graves' disease at two academic medical centers, one in North America (New Orleans, LA) and one in Europe (Paris, France). RESULTS: A total of 102 patients were included, of which 56 (55%) underwent robotic thyroidectomy and 46 (45%) underwent conventional open cervical thyroidectomy. Mean age was 40.2 ± 13.2 years and 94 (92%) were females. Mean BMI for the sample was 27.7 ± 10.2 kg/m2. There was a trend towards larger specimen volume in the robotic-assisted group, 84.9 ± 62.2 cm3 versus 65.2 ± 40.5 cm3 (p = 0.07). Mean length of stay for the French patients undergoing robotic-assisted surgery was 3.2 ± 0.5 days. For the American cohort, length of stay was significantly shorter for robotic-assisted thyroidectomy, at 0.8 ± 0.4 days versus 1.0 ± 0.2 days (p = 0.003). Operative time was longer in patients who underwent robotic thyroidectomy (174.4 ± 33.5 min) compared to patients who underwent traditional cervical approach (121.2 ± 41.1 min, p < 0.0001). There was no difference in complication rates for the overall sample of patients undergoing robotic-assisted or open cervical procedures. CONCLUSION: Robotic thyroid surgery is safe in a select group of patients with Graves' disease in the Western population. Additional studies are warranted to further investigate these findings.

Successful Treatment of Differentiated Thyroid Carcinoma with Transaxillary Robotic Surgery and Radioiodine: The First European Experience.

OBJECTIVES: Transaxillary robotic thyroidectomy surgery (TARS) has been reported to be a safe approach in patients with differentiated thyroid carcinoma, and oncological responses are promising. STUDY DESIGN: This study aimed to evaluate the oncological outcomes of TARS followed by radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma. Between 2011 and 2016, patients treated for differentiated thyroid carcinoma by TARS in a single institution, followed by RAI, were retrospectively included. The oncological response was performed according to the 2015 American Thyroid Association (ATA) guidelines 6-12 months later and at the last available visit. RESULTS: A total of 42 patients (30 females) were included, with a median tumor size of 20 mm (12 cases of N1a and 5 cases of N1b on initial pathology report). According to ATA classification of recurrence risk after surgery, 17 and 25 patients were classified as low and intermediate risk, respectively. After RAI, all patients had a normal posttherapeutic whole body scan (except 1 patient, who had pathological lymph node uptake), but no unusual uptake was seen. At the 6- to 12-month evaluation (n = 37), 24 patients had excellent response, 8 had indeterminate response, and 5 had incomplete response (2 biological and 3 structural); no distant metastasis was found. At the last evaluation (median follow-up 15.9 months), 35 patients had no evidence of disease and 1 patient had a structural incomplete response. In total, a second open surgery was necessary for 3 patients to treat persistent lymph nodes (all intermediate risk). CONCLUSION: In this study, TARS followed by RAI therapy seems to be curative, even for patients with lymph node metastases, after good preoperative staging. More studies are required to confirm the findings.

Robotic Thyroid Surgery: Current Perspectives and Future Considerations.

Robotic transaxillary thyroidectomy, pioneered in South Korea, is firmly established throughout the Far East but remains controversial in Western practice. This relates to important population differences (anthropometry and culture) compounded by the smaller mean size of thyroid nodules operated on in South Korea due to a national thyroid cancer screening programme. There is now level 2 evidence (including from Western World centres) to support the safety, feasibility, and equivalence of the robotic approach to its open counterpart in terms of recurrent laryngeal nerve injury, hypoparathyroidism, haemorrhage, and oncological outcomes for differentiated thyroid cancer. Moreover, robotic thyroidectomy has been shown to be superior to open surgery for certain patient-reported outcome measures, namely scar cosmesis and pain. Downsides include its high cost, longer operative time, and risk of complications not encountered in open thyroidectomy (brachial plexus neurapraxia). Careful patient selection is paramount as this procedure is not for every patient, surgeon, or hospital. It should only be undertaken by high-volume surgeons operating as part of a multidisciplinary robotic team in specialised centres. Novel robotic approaches utilising the retroauricular and transoral routes for thyroidectomy have recently been described but further studies are required to establish their respective role in modern thyroid surgery.

Gasless trans-axillary robotic thyroidectomy: the introduction and principle.

A historic review of the main stages of evolution of the minimally-invasive techniques in thyroid surgery. The endoscopic era is divided into direct and indirect approaches. Examples are the minimally invasive video-assisted thyroidectomy (MIVAT) and the minimally invasive lateral approach. The indirect approach is divided into transaxillary and chest/breast incisions. A brief historic review of the advent of robots to the medical and mainly surgical field. And finally, an introduction to transaxillary robotic thyroidectomy.

Robotic transaxillary thyroid surgery.

Recent technological advances have led to a rapid progress in endocrine surgery. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has emerged as one of the most promising approaches. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, increased patient satisfaction, improved visualization, arms articulations, eliminating surgeon's natural tremor, thereby increasing precision. The main disadvantages are longer operative time, and increased cost compared to conventional thyroidectomy, as well as potential injuries to the brachial plexus, skin flap, esophagus, and trachea. Large-scale studies, mainly from South-Korea, have proved that in skilled hands, RATS is a safe alternative to conservative thyroidectomy and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial, and further evidence must be sought to confirm its indications.

Robot-assisted transaxillary thyroid surgery-feasibility and safety of a novel technique.

Developments in technology have led to a rapid progress in robotic endocrine surgery applications. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has emerged as one of the most promising approaches. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, thereby increasing patient satisfaction, and improved visualization, arms articulations, and precision, resulting in fewer surgical complications. The main disadvantages are potential new injuries to the brachial plexus, esophagus, and trachea, longer operative time, and increased cost compared to conventional thyroidectomy. In skilled hands, RATS is a safe alternative to conservative thyroidectomy and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial, and further evidence must be sought to confirm its indications over time.

Anesthetic implications for robot-assisted transaxillary thyroid and parathyroid surgery: a report of twenty cases.

Gasless transaxillary robot-assisted endoscopic thyroid surgery has recently been proposed and developed in South Korea and the United States. Perianesthetic implications and their evolution for 20 patients scheduled to undergo this innovative surgical technique are presented. The anesthetic considerations focus on the length of surgery due to the learning curve, the risk of the ipsilateral arm posture, and postoperative pain evaluation and management.

Indications for the gasless transaxillary robotic approach to thyroid surgery: experience of forty-seven procedures at the american hospital of paris.

BACKGROUND: Thyroid surgery is in a state of evolution from traditional open approaches to novel robotic techniques. The gasless transaxillary approach to thyroid surgery is effective in the management of thyroid cancer, and complications after robotic thyroidectomy are no higher than experienced after open or endoscopic techniques. The transaxillary robotic approach also avoids an anterior neck scar. This paper presents what the authors believe to be the largest cohort of patients reported in Europe undergoing gasless transaxillary robotic thyroid surgery, with the aim of defining the indications for this procedure. METHODS: Forty-six patients underwent robotic thyroid surgery via the transaxillary approach and were enrolled in this study between March 2010 and September 2012. All patients were operated on by one surgeon at one clinical center. Reviewed data included patient characteristics, pathological characteristics, extent of surgery and postoperative complications. The mean follow-up time was 7.29 months. RESULTS: Forty-six patients underwent 47 procedures, the average age of the patients was 43 years and the male to female ratio was 1:22. Undertaken were 30 lobectomies, 3 subtotal thyroidectomies, 13 total thyroidectomies and 1 totalization. One case was converted to an open procedure. The ratio of malignant to benign disease was 1:6.67 (6:40 cases) and analysis of the surgical specimens showed 6 follicular lesions, 24 follicular adenomas, 3 colloid lesions, 1 case of thyroiditis/lymphatic lesion, 3 adenomatoid lesions, 3 oncocytic adenomas, 3 papillary cancers and 3 microcapillary cancers. The overall average size of an individual specimen removed was 45.40 ± 28.95 cm(3) (range 5-160, n = 47) and the average largest diameter of the lesion removed was 3.72 ± 0.95 cm (range 1.4-6.0, n = 47). Postoperatively, there were 5 recurrent laryngeal nerve injuries (4 transient), 2 transient brachial plexopathies, 1 case of postoperative dysphagia and 1 of collection of blood at the site of surgery. There were no cases of disease recurrence at follow-up. CONCLUSIONS: The gasless robotic transaxillary approach to thyroid surgery has been predicted to become a standard technique. It has been shown to be efficacious in the management of thyroid cancer with lateral neck metastases; however, more data relating to oncological safety in long-term follow-up is required. This intervention is also appropriate for benign thyroid disease including Graves' disease. To achieve consistently successful results, careful patient selection is fundamental in terms of patient characteristics and the anatomical aspects of the lesion. This is especially important with a geographical expansion to include North America and Europe. The excellent cosmetic results of this procedure make it ideal for patients who have esthetic concerns regarding particular difficulties with healing; however, in common with all new surgical procedures, further evidence must be sought to confirm its indications over time.