Prevention of hypoparathyroidism with indocyanine green in transoral thyroidectomy: Pilot study
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Keywords
Hypoparathyroidism, Parathyroid Glands, Thyroidectomy, Indocyanine Green, Natural Orifice Endoscopic Surgery
Abstract
Abstract
Background: The prevalence of hypoparathyroidism following thyroidectomy is estimated to range from 15%, with a higher incidence observed in transoral endoscopic thyroidectomy via vestibular approach (TOETVA).
Objective: To describe the impact of intraoperative use of indocyanine green (ICG) to identify parathyroid glands in reducing postoperative hypoparathyroidism.
Material and methods: A pilot, observational, comparative, longitudinal, and ambispective study was conducted in a cohort of 55 patients who underwent laparoscopic thyroidectomy via TOETVA. Calcium (Ca) and parathyroid hormone (PTH) levels were compared immediately and 24 hours after surgery.
Results: The mean age was 43.07 years (standard deviation ± 10.15). The average surgery time was 99.15 minutes (± 20.02), and the mean blood loss was 9.3 mL (± 15.9). The prevalence of biochemical postoperative hypoparathyroidism (PTH < 12 pg/mL) was 5.54%. Biochemical hypocalcemia occurred in 19 patients (34.5%), and 4 patients (7.3%) experienced clinical hypocalcemia with paresthesia. Patients were divided into 2 groups: with and without the use of ICG. No significant differences were found in the incidence of hypocalcemia or hypoparathyroidism between the 2 groups (p = 0.360 and p = 1.000, respectively).
Conclusion: No differences were found in surgery time, blood loss, clinical hypocalcemia, or postoperative calcium and PTH levels.
References
1. Takahashi T, Yamazaki K, Shodo R, et al. Actual prevalence of hypoparathyroidism after total thyroidectomy: a health insurance claims-database study. Endocrine. 2022;78(1):151-8. doi: 10.1007/s12020-022-03153-1
2. Gangappa RB, Kenchannavar MB, Chowdary PB, et al. Total thyroidectomy for benign thyroid diseases: What is the price to be paid? J Clin Diagn Res. 2016;10(4):PC04-7.
3. Al Argan RJ, Alkhafaji DM, AlQahtani SY, et al. Prevalence and predictors of postoperative hypoparathyroidism: A multicenter observational study. J Clin Med. 2025;14(7):2436. doi: 10.3390/jcm14072436
4. Schopf S, Umschlag C, Mechera R, et al. [Indications and technique for transoral thyroid gland and parathyroid gland surgery] [Article in German]. Chirurgie (Heidelb). 2024;95(10):801-9. doi: 10.1007/s00104-024-02118-6
5. Menderico Jr GM, Weissenberg AL, Borba CM, et al. Complications of transoral endoscopic thyroidectomy vestibular approach (TOETVA). Rev Col Bras Cir. 2021;48:e20202557. doi: 10.1590/0100-6991e-20202557
6. Anuwong A. Transoral endoscopic thyroidectomy vestibular approach: A series of the first 60 human cases. World J Surg. 2016;40(3):491-7. doi: 10.1007/s00268-015-3320-1
7. Anuwong A, Ketwong K, Jitpratoom P, et al. Safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach. JAMA Surg. 2018;153(1):21-7. doi: 10.1001/jamasurg.2017.3366
8. Orloff LA, Wiseman SM, Bernet VJ, et al. American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults. Thyroid. 2018;28(7):830-41. doi: 10.1089/thy.2017.0309
9. Abdelrahman H, El-Menyar A, Peralta R, et al. Application of indocyanine green in surgery: A review of current evidence and implementation in trauma patients. World J Gastrointest Surg. 2023;15(5):757-75. doi: 10.4240/wjgs.v15.i5.757
10. Lim ZY, Mohan S, Balasubramaniam S, et al. Indocyanine green dye and its application in gastrointestinal surgery: The future is bright green. World J Gastrointest Surg. 2023;15(9):1841-57. doi: 10.4240/wjgs.v15.i9.1841
11. Alander JT, Kaartinen I, Laakso A, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging. 2012;2012:940585. doi: 10.1155/2012/940585
12. Moreno P, García A, Francos JM, et al. Angiografía intraoperatoria con verde de indocianina (ICG) de las glándulas paratiroides para predecir la hipocalcemia postiroidectomía: análisis comparativo de 2 sistemas de puntuación (ICG-2 vs. ICG-4). Cir Esp. 2022;100(5):274-80. doi: 10.1016/j.ciresp.2021.03.017
13. Ngo QX, Ngo DQ, Le DT, et al. Transoral endoscopic thyroidectomy vestibular approach versus conventional open thyroidectomy for the treatment of benign thyroid tumours: A prospective cohort study. J Minim Access Surg. 2024;20(4):403-7. doi: 10.4103/jmas.jmas_197_23
14. Wang SH, Chao WP, Lo TY, et al. Comparison of surgical outcomes of transoral versus open thyroidectomy for Graves disease. Surg Laparosc Endosc Percutan Tech. 2024;34(2):150-5.
15. Yin S, Pan B, Yang Z, et al. Combined use of autofluorescence and indocyanine green fluorescence imaging in the identification and evaluation of parathyroid glands during total thyroidectomy: a randomized controlled trial. Front Endocrinol (Lausanne). 2022;13:897797. doi: 10.3389/fendo.2022.897797
16. Richard M, Rizo P. Feasibility of parathyroid gland autofluorescence imaging after indocyanine green fluorescence angiography. Front Endocrinol (Lausanne). 2023;14:1248449. doi: 10.3389/fendo.2023.1248449
17. Shaphaba K, Thakar A, Sakthivel P, et al. Incremental value of magnification and indocyanine green for parathyroid preservation in thyroid surgery. Head Neck. 2023;45(7):1663-71. doi: 10.1002/hed.27387
18. Moreno-Llorente P, García-Barrasa A, Pascua-Solé M, et al. Usefulness of ICG angiography-guided thyroidectomy for preserving parathyroid function. World J Surg. 2023;47(2):421-8. doi: 10.1007/s00268-022-06683-x
19. Oh MY, Lee MJ, Lee JM, et al. Standardized intraoperative neuromonitoring procedure is feasible in transoral endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech. 2022;32(6):661-5. doi: 10.1097/SLE.0000000000001112
20. Kuo TC, Duh QY, Wang YC, et al. Practice patterns and learning curve in transoral endoscopic thyroidectomy vestibular approach with neuromonitoring. Front Endocrinol (Lausanne). 2021;12:744359. doi: 10.3389/fendo.2021.744359
21. Motiee-Langroudi M, Farahzadi A, Shirkhoda M, et al. Identifying and preserving parathyroid glands during thyroid surgery using indocyanine green and a review of the literature. Cancer Rep (Hoboken). 2025;8(6):e70226. doi: 10.1002/cnr2.70226
22. Solórzano CC, Thomas G, Berber E, et al. Current state of intraoperative use of near infrared fluorescence for parathyroid identification and preservation. Surgery. 2021;169(4):868-78. doi: 10.1016/j.surg.2020.09.014
23. Rupp GE, Barba P, Goldhaber NH, et al. Indocyanine green fluorescence-guided resection of carotid sheath parathyroid adenoma: a case report and literature review. Gland Surg. 2023;12(4):548-54. doi: 10.21037/gs-22-589
24. Zhang X, Zhao WY, Li GL, et al. Comparison of Transoral Endoscopic Thyroidectomy via the Vestibular Approach and Conventional Open Thyroidectomy for Papillary Thyroid Carcinoma: A Propensity Score-Matched Analysis. Ann Surg Oncol. 2025;32(9):6765-73. doi: 10.1245/s10434-025-17655-5
25. Wu X, Liu H, He J, et al. Postoperative quality of life in patients treated for thyroid cancer with transoral endoscopic and open surgery. Sci Rep. 2025;15(1):7257. doi: 10.1038/s41598-025-91291-7
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