Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, Pediatric Surgery family. I'm Em Gootee 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 in 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 Hamb 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 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 a 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 postoperative hypocalcemia. and improve parathyroid preservation after total thyroidectomy. Parathyroids can auto -fluoresce, so there's a fluo -beam system in addition to the probe system, and they noted hypocalcemia rates that were about half with
using it 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 controlled 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. So this just shows an example where you can see the thyroid gland lifted and exposed. And then with the autofluorescence, you can see 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 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 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 re -implantation? 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've 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 that the actual real -life use of it may not be as good as advertised. It's helpful to have the reps 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... 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 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.