Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review From the American Head and Neck Society Endocrine Surgery Section.

Importance: Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery. Observation: This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery. Conclusions and Relevance: Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.

Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases.

INTRODUCTION: Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars. METHODS: Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021. RESULTS: Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. CONCLUSTIONS: Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.

International Multi-institutional Experience with the Transoral Endoscopic Thyroidectomy Vestibular Approach.

Background: Surgical approaches to thyroidectomies have undergone a rapid evolution over the past three decades. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is currently the latest remote access procedure for the treatment of benign and malignant thyroid disease. The purpose of this article is to present the results of TOETVA from five different international institutions. Materials and Methods: From 2016 to 2019, 152 TOETVA procedures were performed on 149 patients at five separate international institutions. Outcomes were analyzed from a prospectively maintained database. There were 12 (8%) men and 137 (92%) women with mean ages of 41.5 ± 10.3 (27-69) and 46.9 ± 1.8 (17-78), respectively. Results: There were 3 (2%) cases that required conversion from the endoscopic approach to an open procedure. A thyroid lobectomy was performed in 111 (73.0%) cases, total thyroidectomy in 38 (25.0%) cases whereas a completion thyroidectomy in 3 (2.0%) cases. Mean operative times were 161.8 ± 42.4 (83-304) minutes for the lobectomy, 213.4 ± 71.7 (120-430) minutes for the total thyroidectomy, and 136.7 ± 109.8 (64-263) minutes for the completion thyroidectomy. The final pathology report revealed 107 (70.4%) benign nodules, 44 (28.9%) nodules with underlying papillary thyroid carcinoma, and 1 (0.7%) case with Hurthle cell carcinoma. Of the 152 cases, 7 (4.7%) patients developed temporary hypoparathyroidism. There were 5 (3.3%) patients who developed transient recurrent laryngeal nerve (RLN) injury and 3 (2.0%) with persistent injury of the RLN. Temporary lower lip numbness was noted in 51 (33.6%) patients whereas 1 (0.7%) patient was noted to have persistent numbness. We reported 57 (38.5%) patients with temporary chin numbness, 9 (5.9%) patients with skin injuries, and 2 (1.3%) with tracheal perforation. Conclusion: To date, the literature and the outcomes from these 5 international institutions have determined that, in select patients, TOETVA can be as safe and efficacious as the traditional trans-cervical technique for the treatment of specific thyroid pathologies.

Usefulness of near-infrared angiography for identifying the intersegmental plane and vascular supply during video-assisted thoracoscopic segmentectomy.

OBJECTIVES: Segmentectomy by video-assisted thoracoscopic surgery (VATS) permits anatomical resection for diagnosis and treatment of small lung nodules but requires that intersegmental planes and segmental vessels be identified accurately. Near-infrared angiography with systemic injection of indocyanine green (ICG) can precisely identify the intersegmental plane. The purpose of this study was to confirm the usefulness of ICG angiography during VATS segmentectomy. METHODS: We retrospectively reviewed the records of 22 consecutive patients who underwent VATS segmentectomy performed with near-infrared angiography between November 2014 and October 2015. Segments were localized and anatomical vascular supply was identified on preoperative computed tomography scans. VATS segmentectomy was performed using an anterior approach with 2 ports and 1 non-spreading minithoracotomy, with ICG injected systemically after arterial ligation. RESULTS: VATS was feasible for all 22 segmentectomies, and in all patients, the intersegmental plane was identified accurately by ICG angiography. This angiography method was also useful in patients whose anatomical vascular segmentation was difficult to identify and, in a few patients, to assess the distribution of an artery before sectioning, to determine the vascular supply of the remaining lung and to distinguish between segmental and intersegmental veins. The postoperative course was uneventful for 18 patients and complicated for 2 patients who had prolonged air leak (10 and 15 days) with pneumonia, 1 patient with gastroparesis and 1 with colonic ileus. The drain was removed before the 3rd postoperative day in all but 2 patients, and the mean hospital stay was 5.4 ± 4.5 days. Anatomopathological examination indicated that 4 benign lesions and 18 primary lung cancers were completely removed, including 14 that were Stage IA, 2 Stage IIA and 2 Stage IIIA. CONCLUSIONS: Indocyanine green angiography provides technical support for identifying the intersegmental plane and the vasculature during VATS segmentectomy. It contributes to the quality of diagnostic and therapeutic excisions of small nodules that are often not visible and not palpable during VATS.

A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques.

Identification of the parathyroid glands (PGs) during thyroid surgery may prevent their inadvertent surgical removal and prevent postoperative hypoparathyroidism. However, identification of the PGs does not guarantee their function, and their vascular supply needs to be preserved as well. The recent introduction of intraoperative indocyanine green (ICG) fluorescent angiography of the PGs during thyroid surgery allows for the appraisal of the vascular anatomy and evaluation of PG function. The use of this tool could lead to a significant reduction in the rate of postoperative hypoparathyroidism, as it allows surgeons to adapt their surgical technique for the preservation of the PGs. ICG fluorescent angiography is currently the only available real-time tool to assess the vascular blood supply of each individual PG intraoperatively and can thus assist surgeons in their decision-making. Herein, we review the relevant literature.

Odd localisation for a gastric cancer histology.

INTRODUCTION: More than 96% of signet-ring cell carcinomas occur in the stomach and the rest in other organs, including the gallbladder, pancreas, urinary bladder and breast. Primary signet-ring cell carcinoma of the colon and rectum is very rare, accounting for 0.1%-2.4% of all colorectal cancers. PRESENTATION OF CASE: We report a case of a 55-year old man who is operated for a caecal mass evocative of an appendicitis abscess. Intraoperatively, we discover a large, ulcerated ilio-caecal mass with several lymphadenopathies. The further workup reveals a primary signet-ring cell carcinoma of the colon with multiple lymph nodes and osteolytic bony metastases. DISCUSSION: Primary signet-ring cell carcinoma of the colon and rectum presents usually as an advanced stage disease with a dismal prognosis. It spreads mainly to the lymph nodes and to the peritoneum and very rarely to the liver. The mean age of patients diagnosed with primary signet-ring cell carcinoma is significantly younger than for ordinary adenocarcinoma. The upper endoscopy is the investigation of choice to exclude a primary gastric pathology. There are very few reports about this type of cancer and no reports about this type of cancer associated with osteolytic bony metastases. CONCLUSION: The characteristics and pathophysiology of a primary signet-ring cell carcinoma of the colon and rectum are not well understood. Usually only palliative treatment is possible. The importance of an early diagnosis of this tumor is mandatory to have a curative approach.

Intra-Operative Indocyanine Green Angiography of the Parathyroid Gland.

Major complications of thyroid and parathyroid surgery are recurrent laryngeal nerve injuries and definitive hypoparathyroidism. The use of intra-operative Indocyanine Green Angiography for confirmation of vascular status of the parathyroid gland is reported here.

Subtotal Parathyroidectomy Under Indocyanine Green Angiography.

Introduction: Subtotal parathyroid resection is indicated when secondary or tertiary hyperparathyroidism (HPT) develops and may be indicated also in patients with primary HPT and multiglandular disease. Three different surgical procedures are used to treat diffuse parathyroid hyperplasia: total parathyroidectomy with or without autotransplantation, and subtotal parathyroidectomy. One of the main complications is transient or persistent hypoparathyroidism. In this video, we show our technique of subtotal parathyroidectomy using a fluorescent dye (indocyanine green [ICG]) to check for the vascularization of the parathyroid remnant, to avoid definitive postoperative hypoparathyroidism. Methods: We present a 64-year-old man with end-stage chronic kidney disease dialyzed since 2008. His parathyroid hormone (PTH) level was 106 pmol/L, corrected calcium level was 2.29 mmol/L and phosphate 1.63 mmol/L under maximal medical treatment, and he had significant bone disease. A subtotal parathyroidectomy was scheduled. After reclining pre-thyroid muscles, we medialized the right thyroid lobe to expose the right parathyroid glands. The superior one was a good candidate to be preserved partially because it looked hyperplastic, but without a macroscopic nodule and was the smallest of the four parathyroid glands. The inferior one was located deep in the mediastinum, in the thymus, and was therefore not suitable for subtotal resection. The procedure was the same for the left side. The inferior parathyroid gland harbored nodular hyperplasia and, therefore, was not very suitable for partial resection, but the superior one looked as a good candidate for subtotal resection too. We started reducing the volume of the parathyroid glands with clips, preserving carefully each parathyroid's vascular pedicle. Then, we intravenously injected 3.5 mL of indocyanine green solution to check the perfusion of the parathyroid remnant, using a fluorescent imaging camera (PINPOINT camera; Novadaq, Mississauga, ON, Canada). The perfusion can be seen as green or white, depending on the selected image mode. We finally chose the right superior parathyroid gland and resected the gland outside of the clips. The other glands have finally been entirely removed. Results: The postoperative course was uneventful except for hypocalcemia needing intravenous calcium for 48 hours. On the first postoperative day, corrected calcium level was 1.93 mmol/L and PTH level was 8 pmol/L. The two inferior parathyroid glands showed nodular hyperplasia at pathologic examination and the two superior glands showed diffuse hyperplasia without nodules. Conclusion: With this new procedure, subtotal parathyroidectomy under ICG angiography, we can check for the good vascularization of the parathyroid remnant before resecting the other parathyroid glands. Therefore, we can intraoperatively guarantee the absence of definitive hypoparathyroidism. This technique is safe, reproducible, and its easy use makes it the procedure of choice in these situations, when the device is available. No competing financial interests exist. Runtime of video: 6 mins 33 secs.

Surgery of the thyroid: recent developments and perspective.

In the past century, thyroid surgery has benefited from physiological and technical revolutions. In the early 1900s, the most important aspect of thyroidectomy was the volume resected, without knowledge of exactly what was removed and if there were important structures around the thyroid gland. The main indications were respiratory problems for tracheal compression and the death rate was greater than 36% due to bleeding, infections, unrecognised bilateral recurrent laryngeal nerve lesions and unrecognised severe hypocalcaemia leading to tetany. At some point this surgery was, therefore, banned in some countries such as France and the United States. Today, thyroid surgery is a common surgery: about 45,000 thyroidectomies are performed per year in France, 60,000 in Germany and 4,000 in Switzerland. Thyroid surgery has become very safe with a mortality of almost 0% and a very low complication rate. In our centre, the number of thyroidectomies has more than tripled in the last decade. There are many indications leading to thyroid surgery, but the three main indications covering 90% of the interventions are cancer (or suspected cancer), hyperthyroidism and size / volume / intrathoracic goitres. In this paper, we highlight some historical points, describe important knowledge and technical improvements made during the last century and give our opinion on expected evolution in this field for the near future.

Towards a mathematical theory of meaningful communication.

Meaning has been left outside most theoretical approaches to information in biology. Functional responses based on an appropriate interpretation of signals have been replaced by a probabilistic description of correlations between emitted and received symbols. This assumption leads to potential paradoxes, such as the presence of a maximum information associated to a channel that creates completely wrong interpretations of the signals. Game-theoretic models of language evolution and other studies considering embodied communicating agents show that the correct (meaningful) match resulting from agent-agent exchanges is always achieved and natural systems obviously solve the problem correctly. Inspired by the concept of duality of the communicative sign stated by the swiss linguist Ferdinand de Saussure, here we present a complete description of the minimal system necessary to measure the amount of information that is consistently decoded. Several consequences of our developments are investigated, such as the uselessness of a certain amount of information properly transmitted for communication among autonomous agents.

Emergence of Zipf's law in the evolution of communication.

Zipf's law seems to be ubiquitous in human languages and appears to be a universal property of complex communicating systems. Following the early proposal made by Zipf concerning the presence of a tension between the efforts of speaker and hearer in a communication system, we introduce evolution by means of a variational approach to the problem based on Kullback's Minimum Discrimination of Information Principle. Therefore, using a formalism fully embedded in the framework of information theory, we demonstrate that Zipf's law is the only expected outcome of an evolving communicative system under a rigorous definition of the communicative tension described by Zipf.

Diversity, competition, extinction: the ecophysics of language change.

As indicated early by Charles Darwin, languages behave and change very much like living species. They display high diversity, differentiate in space and time, emerge and disappear. A large body of literature has explored the role of information exchanges and communicative constraints in groups of agents under selective scenarios. These models have been very helpful in providing a rationale on how complex forms of communication emerge under evolutionary pressures. However, other patterns of large-scale organization can be described using mathematical methods ignoring communicative traits. These approaches consider shorter time scales and have been developed by exploiting both theoretical ecology and statistical physics methods. The models are reviewed here and include extinction, invasion, origination, spatial organization, coexistence and diversity as key concepts and are very simple in their defining rules. Such simplicity is used in order to catch the most fundamental laws of organization and those universal ingredients responsible for qualitative traits. The similarities between observed and predicted patterns indicate that an ecological theory of language is emerging, supporting (on a quantitative basis) its ecological nature, although key differences are also present. Here, we critically review some recent advances and outline their implications and limitations as well as highlight problems for future research.