Use of Indocyanine Green and Fluorescence Angiography in Parathyroid Surgery: A Feasibility Study.

Background. Indocyanine green (ICG) with near-infrared (NIR) fluorescence is an established method for assessing vascularity in various clinical settings. We hypothesized that parathyroid adenomas, with increased capillary networks, may demonstrate a fluorescence which could aid intraoperative identification and confirmation of the abnormal parathyroid tissue. Methods. This prospective case-control study compared patients with primary hyperparathyroidism undergoing parathyroidectomy (cases) to normal parathyroid in thyroidectomy patients (controls). After exposing the parathyroid gland, ICG was injected and the fluorescence of parathyroid and thyroid was recorded and graded in comparison to the surrounding tissue and vasculature (0 = nonfluorescent and 5 = vasculature). Results. The intensity of parathyroid fluorescence was more in cases (4 ± 2) than controls (2 ± 1) when graded intraoperatively (P = .001). Thyroid fluorescence did not differ (3 vs 3, P = .072); however, parathyroid fluorescence was more intense than thyroid in cases (parathyroid = 4 ± 2 and thyroid = 3 ± 1, P = .018). Conclusions. ICG fluorescence in diseased parathyroid was more intense than normal parathyroid and thyroid, suggesting the ICG/NIR technology may be a useful intraoperative tool for identification of abnormal parathyroid.

Perforated pre-pyloric ulcer in the gastric remnant over a decade after Roux-en-Y gastric bypass: A case report.

INTRODUCTION AND IMPORTANCE: Roux-en-Y gastric bypass (RYGB) is one of the two most common weight loss surgeries. Surgical emergencies after gastric bypass can be complicated by devastating events that are often difficult to diagnose and manage. Perforated ulcers are a very rare complication after a RYGB. CASE PRESENTATION: In this report, the diagnosis and surgical management of a 59-year-old immunosuppressed male patient who presented with late perforation of a pre-pyloric ulcer in the gastric remnant after RYGB is presented. The perforation was repaired transversely in a running horizontal mattress fashion and patched with a piece of well-vascularized omentum. CLINICAL DISCUSSION: This case illustrates the potential for gastric remnant ulceration, even a decade after RYGB. A high degree of suspicion for the diagnosis of perforated remnant stomach is required, especially in the absence of pneumoperitoneum and free fluid. Patient-specific factors, such as immunosuppression in this case, may blunt normal physiologic response. CONCLUSION: Considering the location of the ulcer in the pre-pyloric area, we caution that the typical paradigm of marginal ulceration of the gastro-jejunal anastomosis does not always apply when evaluating gastric complications after RYGB.

Use of fluorescence imaging and indocyanine green during thyroid and parathyroid surgery: Results of an intercontinental, multidisciplinary Delphi survey.

BACKGROUND: In recent years, fluorescence imaging-relying both on parathyroid gland autofluorescence under near-infrared light and angiography using the fluorescent dye indocyanine green-has been used to reduce risk of iatrogenic parathyroid injury during thyroid and parathyroid resections, but no published guidelines exist regarding its use. In this study, orchestrated by the International Society for Fluorescence Guided Surgery, areas of consensus and nonconsensus were examined among international experts to facilitate future drafting of such guidelines. METHODS: A 2-round, online Delphi survey was conducted of 10 international experts in fluorescence imaging use during endocrine surgery, asking them to vote on 75 statements divided into 5 modules: 1 = patient preparation and contraindications to fluorescence imaging (n = 11 statements); 2 = technical logistics (n = 16); 3 = indications (n = 21); 4 = potential advantages and disadvantages of fluorescence imaging (n = 20); and 5 = training and research (n = 7). Several methodological steps were taken to minimize voter bias. RESULTS: Overall, parathyroid autofluorescence was considered better than indocyanine green angiography for localizing parathyroid glands, whereas indocyanine green angiography was deemed superior assessing parathyroid perfusion. Additional surgical scenarios where indocyanine green angiography was thought to facilitate surgery are (1) when >1 parathyroid gland requires resection; (2) during redo surgeries, (3) facilitating parathyroid autoimplantation; and (4) for the predissection visualization of abnormal glands. Both parathyroid autofluorescence and indocyanine green angiography can be used during the same procedure and employing the same imaging equipment. However, further research is needed to optimize the dose and timing of indocyanine green administration. CONCLUSION: Though further research remains necessary, using fluorescence imaging appears to have uses during thyroid and parathyroid surgery.

Outdated and incomplete: a review of thyroid cancer on the World Wide Web.

OBJECTIVE: To evaluate the most frequently searched thyroid cancer websites for completeness, accuracy, and consumer friendliness. DESIGN: The 50 most popular thyroid cancer websites were evaluated using a novel instrument developed by a Delphi panel of endocrine experts and based on practice guidelines. Each website received independent scores for disease-specific information and a final quality score. Quality was related to website demographics using the Student t test, chi-square, and ANOVA analyses. MAIN OUTCOMES: Interrater reliability was excellent (kappa = 0.81). Most websites were not specific to thyroid cancer alone (72%), contained advertisements (72%), lacked references (66%), and were privately sponsored (50%). Only 38% had been updated within 2 years. "Government" and "Non-Profit" websites were the most consumer friendly. Mean quality score of medical content was 38%, with websites receiving the highest score in "Anatomy/Physiology" (55%) and lowest in "Surgery" (29%). Low quality score was attributed to information deficiency rather than inaccuracy. On univariate analysis, no significant associations were found between quality score and country of origin, currency, sponsorship, authorship, administration, advertisements, or references. CONCLUSIONS: Thyroid cancer websites are out of date and incomplete, lacking important information sought by patients, particularly surgical information. An accurate, comprehensive, easily available, and patient-oriented thyroid cancer Internet resource is needed for patients.

Gastrointestinal manifestations of endocrine disease.

The hormonal interactions among the systems throughout the body are not fully understood; many vague clinical symptoms may in fact be manifestations of underlying endocrine diseases. The aim of the following review is to discuss gastrointestinal manifestations of surgically correctable endocrine diseases, focusing on abnormalities of thyroid function, cancer and finally autoimmune diseases. We also review manifestations of pancreatic endocrine tumors, and multiple endocrine neoplasia.

Of duty hour violations and shift work: changing the educational paradigm.

BACKGROUND: Successful surgical education balances learning opportunities with Accreditation Council on Graduate Medical Education (ACGME) duty hour requirements. We instituted a night shift system and hypothesized that implementation would decrease duty hour violations while maintaining quality education. METHODS: A system of alternating teams working 12-hour shifts was instituted and was assessed via an electronic survey distributed at 2, 6, and 12 months after implementation. Resident duty hour violations and resident case volume were evaluated for 1 year before and 2 years after implementation of the night shift system. RESULTS: Survey data revealed a decrease in the perception that residents had problems meeting duty hour restrictions from 44% to 14% at 12 months (P = .012). Total violations increased 26% in the 1st year, subsequently decreasing by 62%, with shift length violations decreasing by 90%. Resident availability for didactics was improved, and average operative cases per academic year increased by 65%. CONCLUSIONS: Night shift systems are feasible and help meet duty hour requirements. Our program decreased violations while increasing operative volume and didactic time.

Indocyanine green fluorescence-guided redo parathyroidectomy.

Re-operative neck surgery for hyperparathyroidism is a technically difficult operation that requires adjunctive studies to assist with finding the parathyroid tissues. Intraoperative tests help minimise exploration of the neck and decrease injuries to the surrounding structures. Indocyanine green is a near-infrared fluorescent dye that in pre-clinical models was found to be useful in locating the parathyroid glands of dogs. No study has yet reported its use as a tool for parathyroid localisation in humans. We investigated the use of indocyanine green to assist with localisation of a recurrent parathyroid adenoma using a near-infrared imaging system. After exposure of the neck tissues, the parathyroid gland fluoresced brightly and directed our dissection. Exploration of the neck was minimal, and allowed for fast localisation and excision of the adenoma. Overall, use of indocyanine green is a simple and safe technique of intraoperative parathyroid localisation that warrants further investigation.

Filling a void: thyroid cancer surgery information on the internet.

BACKGROUND: Thyroid cancer incidence is increasing, making it an important public health issue. Many patients use the Internet for health-related decisions. Our purposes were to measure the quality of thyroid cancer surgery information on the Internet, and to identify quality predictors. METHODS: The 50 most popular thyroid cancer websites from Google, Yahoo, and MSN were identified. A novel 55-point instrument based on current clinical practice guidelines was designed and used by a Delphi panel of 5 "blinded" endocrine surgeons to assess website information. Each website was independently evaluated by two surgeons. Quality was related to website demographic data using the Student's t-test, chi-square, and ANOVA analyses. RESULTS: Inter-rater reliability for quality scores was excellent (kappa = 0.81). Mean (% of overall quality) score was 21 (38%), and mean score for surgical content was low at 3.5 (29%). Only 50% of sites discussed indications for surgery; 8% length of surgery/anesthesia; 42% the role of lymphadenectomy; 44% recurrent laryngeal nerve injury/hoarseness and 42% hypoparathyroidism as potential complications; 16% recovery; and 20% recommendations for choosing a thyroid surgeon. Only 38% were updated within 2 years. On univariate analysis, no significant associations were found between surgical quality score and website country of origin, currency, sponsorship, authorship, oversight, or references. CONCLUSIONS: Thyroid cancer surgery websites on the Internet are incomplete and outdated. No predictors of quality were identified. Significant improvement is needed in regulating information about thyroid cancer surgery on the Internet, and surgeons may contribute to this effort.

Sonographically guided fine needle aspiration with rapid parathyroid hormone assay.

BACKGROUND: Persistent or recurrent primary hyperparathyroidism (1 degrees HPTH) is ideally treated with limited dissection, based on accurate localization, to minimize operative risks. To accurately localize parathyroid tissue, we employed ultrasound-guided fine needle aspiration (US FNA) with an on-site rapid parathyroid hormone (PTH) assay to confirm localization. METHODS: Of the 272 patients evaluated for 1 degrees HPTH, 34 had persistent or recurrent disease. Standard localization was equivocal in 12, who were referred for US FNA. Suspicious tissue was identified on US and FNA was performed. Analysis with a rapid PTH assay provided on-site result within 12 min. Patients were monitored clinically, and then discharged after observation. RESULTS: Twelve patients were referred for US FNA; eight were female. Ten patients had persistent disease, one had recurrent, and one had 1 degrees HPTH following thyroidectomy. Two of the 12 were excluded due to negative ultrasound examination. Of the remaining ten, positive aspirates were found in nine, and seven proceeded to surgery. In six patients there was 100% correlation between sonographic and operative findings. The remaining patient had no identifiable adenoma, but PTH normalized after arterial ligation. All patients received a limited directed surgical approach, employing cervical block anesthesia in three. Four were discharged on the day of surgery and all were cured. There was one infectious complication of US FNA. CONCLUSIONS: The use of rapid PTH assay can be effectively utilized for localization of parathyroid tissue in remedial parathyroid surgery. Confirmation of localization markedly improves subsequent surgery and allows selective use of minimally invasive techniques.