Introduction Hypoparathyroidism is the most frequent complication after total thyroidectomy and, when permanent, it becomes a severe chronic disease. We assessed the usefulness of indocyanine green (ICG) angiography‐guided thyroidectomy to reduce the postoperative hypocalcemia. Methods Prospective study with two consecutive cohorts of patients who underwent total thyroidectomy: historical control group (CG) and angiography‐guided thyroidectomy group (AG). In all patients, ICG‐angiography was performed at the end of the surgery to predict immediate parathyroid gland (PG) function. In the AG, ICG‐angiography was also done after PG identification to show their vascular supply. We compared the rate of postoperative hypocalcemia (calcium supplementation needed due to hypocalcemia symptoms or calcium levels < 1.8 mmol/L on the first postoperative day) and permanent hypocalcemia (need of calcium ± vitamin D supplementation 12 months after thyroidectomy). Results We included 120 consecutive patients (84 CG; 36 AG). Thyroid cancer was the most common diagnostic (63.1% CG–69.4% AG; p = 0.646) and central neck dissection was also frequent (54.8% CG–64.3% AG; p = 0.468). The AG developed a lower rate of postoperative (26.2–5.6%; p = 0.011) and permanent hypocalcemia (11.9–0%; p = 0.032). The OR for permanent hypocalcemia was 0.673 (95% CI 0.591–0.766). A significant higher rate of well vascularized PG at the end of the surgery (score 2) in the AG (39.2–52.9%; p = 0.018) was also seen. Conclusion ICG angiography‐guided thyroidectomy is a useful tool to identify PG vascularization, allowing a better PG preservation and a significant decrease in hypocalcemia rates.
IntroductionAngiography with indocyanine green (ICG) fluorescence performed before thyroidectomy would allow identification of the vascularization of parathyroid glands, maximizing efforts for preserving functioning glands intraoperatively. The rationale of the study was based on the hypothesis that showing the vascular pattern of the parathyroid glands by means of ICG angiography before performing the thyroidectomy could prevent permanent hypoparathyroidism.Methods and analysisWe propose a randomized single-blind controlled and multicenter clinical trial to assess the efficacy and safety of ICG angiography-guided thyroidectomy to identify the vascular pattern of the parathyroid glands versus conventional thyroidectomy in patients scheduled for elective total thyroidectomy. Patients will be randomized 1:1 to ICG angiography-guided thyroidectomy (experimental group) or conventional thyroidectomy (control group). Patients in the experimental group will undergo ICG angiography before thyroidectomy to identify the feeding vessels of the parathyroid glands and then, post-thyroidectomy ICG angiography to predict immediate parathyroid gland function by scoring the degree of fluorescence of the glands. Patients in the control group will undergo post-thyroidectomy ICG angiography only. The primary outcome measure will be the rate of patients with permanent hypoparathyroidism. Secondary outcome measures will be rate of postoperative hypoparathyroidism, the percentage of well vascularized parathyroid glands remaining in situ, the levels of iPTH and serum calcium after surgery and the influence of the type of vascular pattern of the parathyroid glands over these outcomes, as well as the safety profile of ICG angiography.DiscussionThe results will contribute to adopt a new surgical strategy based on intraoperative ICG angiography before performing total thyroidectomy, according to which the rate of permanent hypoparathyroidism could be substantially reduced.Clinical trial registrationClinicalTrials.gov. identifier NCT05573828.
BackgroundPostoperative hypoparathyroidism is the most common complication after total thyroidectomy and, when becomes permanent, lead to a myriad of clinical symptoms, long-term need of calcium and vitamin D supplementation and negative impact on the patient's health-related quality of life. Any surgical innovation that could reduce complications and improve outcomes of patients undergoing total thyroidectomy deserves to be considered. Angiography-Guided Thyroidectomy has been proposed as a modification of the standard technique of thyroidectomy aimed to identifying the vascular pattern of the parathyroid glands to maximize efforts for preserving functioning glands at the time of operation. Our aim is to provide a technical description of this procedure based on the use of indocyanine green (ICG) angiography to standardize this technique.MethodsThe surgical steps that are followed during a total thyroidectomy are modified due to previous visualization of the feeding vessels of the parathyroid glands according to fluorescence of the vascular mapping obtained by ICG angiography prior to thyroidectomy. The first step is to perform an ICG angiography to assess anatomical features of the feeding vasculature of the parathyroid glands, which allows precise surgical dissection for preservation of the glands. Once the viability of the parathyroids has been evaluated angiographically, thyroidectomy is performed in a second step.ConclusionsICG angiography-guided thyroidectomy may be effective to preserve the largest number of better perfused parathyroid glands, which would contribute to reduce the risk of postoperative and permanent hypoparathyroidism. It can be successfully and safely implemented in thyroid surgery and standardization of the technique is necessary to homogenize this procedure in the future, allowing a better comparation of the results to be published.
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