Publication: Impacto de la autofluorescencia y de la angiografía con verde indocianina durante la tiroidectomía total en la hipocalcemia postoperatoria
Authors
López Morales, Pedro
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Escuela Internacional de Doctorado
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Candel Arenas, María Fe ; Carrasco Prats, Milagros
Publisher
Universidad de Murcia
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DOI
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info:eu-repo/semantics/doctoralThesis
Description
Abstract
INTRODUCCIÓN
La hipocalcemia postoperatoria representa la complicación más frecuente de la tiroidectomía total (TT), a pesar de las diferentes estrategias existentes para su prevención. Suele ser consecuencia de la disminución de parénquima paratiroideo funcionante tras la cirugía. En los últimos años se han reportado buenos resultados con dispositivos que permiten el empleo de la autofluorescencia para facilitar la identificación de las glándulas paratiroides y la realización de una angiografía con verde indocianina (ICG) para valorar su vascularización, lo que se relaciona con su posterior funcionalidad.
OBJETIVOS
El objetivo principal de este trabajo fue analizar el impacto de la autofluorescencia paratiroidea y la angiografía con ICG en las tasas de hipocalcemia postoperatoria e hipoparatiroidismo permanente. Como objetivos secundarios se pretendió correlacionar la viabilidad de las paratiroides en la angiografía con ICG con el desarrollo de hipocalcemia e hipoparatiroidismo, evaluar el número de glándulas identificadas y resecadas de forma inadvertida con esta tecnología en comparación con la inspección visual, así como identificar factores de riesgo para la hipocalcemia postoperatoria y para el hipoparatiroidismo permanente.
MATERIAL Y MÉTODOS
Se trató de un estudio prospectivo realizado por la Unidad de Cirugía Endocrina del Hospital General Universitario Reina Sofía de Murcia. Se incluyeron los pacientes sometidos a una TT durante el primer año tras la adquisición del sistema EleVisionTM IR Head & Neck. En el trascurso de la intervención quirúrgica se empleó la autofluorescencia durante la disección para identificar y respetar las glándulas paratiroides. Una vez completada la tiroidectomía, se realizó una angiografía con ICG para analizar la perfusión de las paratiroides y se otorgó una puntuación entre 0 y 2 a cada glándula identificada en función de su vascularización. Estos pacientes fueron comparados con un grupo control histórico conformado por el mismo número de sujetos de características similares intervenidos con anterioridad a la disponibilidad del dispositivo. Todos los pacientes fueron seguidos durante un mínimo de 6 meses tras la cirugía.
RESULTADOS
Un total de 114 pacientes fueron incluidos en el estudio, 57 en cada grupo. El empleo de la autofluorescencia paratiroidea y la angiografía con ICG se asoció a una reducción en las tasas de hipocalcemia postoperatoria (36,84% vs. 45,61%) y en las de hipoparatiroidismo permanente (8,77% vs. 17,54%). También fue posible objetivar en los pacientes del grupo experimental una disminución de estas complicaciones en pacientes sometidos a vaciamientos ganglionar (40% y 0% vs. 83,33% y 33,33%), en el número de paratiroides resecadas inadvertidamente identificadas en el estudio histológico de la pieza (1 vs. 5), así como en la necesidad de tratamiento con calcio y/o vitamina D al mes de la cirugía (19,30% vs. 36,84%). También fue posible identificar un mayor número de glándulas (184 vs. 170). Sin embargo, solamente resultó estadísticamente significativa la reducción en el tratamiento con calcio y/o vitamina D al mes de la cirugía (p<0,05).
No fue posible establecer una relación entre la puntuación otorgada a las paratiroides en la angiografía con ICG y su funcionalidad postoperatoria, si bien ninguno de los pacientes que desarrollaron hipoparatiroidismo permanente presentaron al menos una glándula bien vascularizada.
CONCLUSIONES
El uso combinado de la autofluorescencia paratiroidea y la angiografía con ICG permitió una reducción en las tasas de hipocalcemia postoperatoria e hipoparatiroidismo permanente. Además, permitió identificar un mayor número de glándulas intraoperatoriamente y disminuir la necesidad de suplementación con calcio y/vitamina D al mes de la cirugía, así como los casos de exéresis paratiroidea inadvertida. Sin embargo, son necesarios estudios con un mayor tamaño muestral para que estas diferencias resulten estadísticamente significativas.
INTRODUCTIONPostoperative hypocalcemia is the most common after total thyroidectomy (TT). However, there are different strategies for its prevention. It is usually caused by a reduction of functional parathyroid parenchyma after surgery. In recent years, good outcomes have been reported with systems that allow the use of autofluorescence to facilitate the identification of parathyroid glands, as well as the performance of an indocyanine green (ICG) angiography to assess their vascularization, which is related to their subsequent functionality.OBJECTIVESThe primary objective of this study was to analyze the impact of parathyroid autofluorescence and ICG angiography on the rates of postoperative hypocalcemia and permanent hypoparathyroidism. Secondary objectives were to correlate parathyroid viability on ICG angiography with the development of hypocalcemia and hypoparathyroidism, to evaluate the number of glands identified and inadvertently resected using this technology compared to visual inspection, and to identify risk factors for postoperative hypocalcemia and permanent hypoparathyroidism.MATERIALS AND METHODSThis was a prospective study conducted by the Endocrine Surgery Unit of the Hospital General Universitario Reina Sofía of Murcia. Patients who underwent TT during the first year after the acquisition of the EleVision(TM) IR Head & Neck system were included. In the course of surgery, autofluorescence was used in the dissection to identify and preserve parathyroid glands. Once thyroidectomy was completed, ICG angiography was performed to assess parathyroid perfusion. A score between 0 and 2 was given to each identified gland according to its vascularization. These patients were compared with the same number of individuals with similar characteristics who underwent surgery before the acquisition of the system (historical control group). All patients were followed up for at least 6 months after surgery.RESULTSA total of 114 patients were included in the study, 57 in each group. The use of parathyroid autofluorescence and ICG angiography was associated with a reduction in the rates of postoperative hypocalcemia (36,84% vs. 45,61%) and permanent hypoparathyroidism (8,77% vs. 17,54%). A decrease in these complications was also observed in experimental group patients who underwent lymph node dissection (40% and 0% vs. 83,33% and 33,33%). The use of EleVision(TM) IR Head system led to a reduction in the number of inadvertently resected identified in the histological study of the specimen (1 vs. 5) as well as the need for calcium and/or vitamin D supplementation one month after surgery (19,30% vs. 36,84%). A higher number of glands was also identified (184 vs. 170). Nevertheless, only the reduction in the need for calcium and/or vitamin D supplementation one month after surgery was statistically significant (p < 0.005).It was not possible to establish a relationship between the score given to the parathyroids on ICG angiography and their postoperative functionality, although none of the patients who developed permanent hypoparathyroidism had at least one well-vascularized gland.CONCLUSIONSThe combined use of parathyroid autofluorescence and ICG angiography allowed a reduction in the rates of postoperative hypocalcemia and permanent hypoparathyroidism. In addition, it allowed the identification of a greater number of parathyroid glands intraoperatively, the reduction in the need for calcium and/or vitamin D supplementation one month after surgery and fewer cases of inadvertent parathyroid resection. However, studies with a larger sample size are needed to achieve statistically significant results.
INTRODUCTIONPostoperative hypocalcemia is the most common after total thyroidectomy (TT). However, there are different strategies for its prevention. It is usually caused by a reduction of functional parathyroid parenchyma after surgery. In recent years, good outcomes have been reported with systems that allow the use of autofluorescence to facilitate the identification of parathyroid glands, as well as the performance of an indocyanine green (ICG) angiography to assess their vascularization, which is related to their subsequent functionality.OBJECTIVESThe primary objective of this study was to analyze the impact of parathyroid autofluorescence and ICG angiography on the rates of postoperative hypocalcemia and permanent hypoparathyroidism. Secondary objectives were to correlate parathyroid viability on ICG angiography with the development of hypocalcemia and hypoparathyroidism, to evaluate the number of glands identified and inadvertently resected using this technology compared to visual inspection, and to identify risk factors for postoperative hypocalcemia and permanent hypoparathyroidism.MATERIALS AND METHODSThis was a prospective study conducted by the Endocrine Surgery Unit of the Hospital General Universitario Reina Sofía of Murcia. Patients who underwent TT during the first year after the acquisition of the EleVision(TM) IR Head & Neck system were included. In the course of surgery, autofluorescence was used in the dissection to identify and preserve parathyroid glands. Once thyroidectomy was completed, ICG angiography was performed to assess parathyroid perfusion. A score between 0 and 2 was given to each identified gland according to its vascularization. These patients were compared with the same number of individuals with similar characteristics who underwent surgery before the acquisition of the system (historical control group). All patients were followed up for at least 6 months after surgery.RESULTSA total of 114 patients were included in the study, 57 in each group. The use of parathyroid autofluorescence and ICG angiography was associated with a reduction in the rates of postoperative hypocalcemia (36,84% vs. 45,61%) and permanent hypoparathyroidism (8,77% vs. 17,54%). A decrease in these complications was also observed in experimental group patients who underwent lymph node dissection (40% and 0% vs. 83,33% and 33,33%). The use of EleVision(TM) IR Head system led to a reduction in the number of inadvertently resected identified in the histological study of the specimen (1 vs. 5) as well as the need for calcium and/or vitamin D supplementation one month after surgery (19,30% vs. 36,84%). A higher number of glands was also identified (184 vs. 170). Nevertheless, only the reduction in the need for calcium and/or vitamin D supplementation one month after surgery was statistically significant (p < 0.005).It was not possible to establish a relationship between the score given to the parathyroids on ICG angiography and their postoperative functionality, although none of the patients who developed permanent hypoparathyroidism had at least one well-vascularized gland.CONCLUSIONSThe combined use of parathyroid autofluorescence and ICG angiography allowed a reduction in the rates of postoperative hypocalcemia and permanent hypoparathyroidism. In addition, it allowed the identification of a greater number of parathyroid glands intraoperatively, the reduction in the need for calcium and/or vitamin D supplementation one month after surgery and fewer cases of inadvertent parathyroid resection. However, studies with a larger sample size are needed to achieve statistically significant results.
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