Unintentional parathyroid gland resection during total thyroidectomy can result in permanent hypoparathyroidism and lifelong replacement therapy. Near infrared autofluorescence (NIRAF) imaging may aid intraoperative identification and preservation of the parathyroid glands. This article aims to review NIRAF's effectiveness in the prevention of post-operative hypoparathyroidism.

Systematic review and meta-analysis reported according to PRISMA guidelines.

The electronic databases of MEDLINE, Embase and Cochrane were searched in September 2024. Included articles were randomised controlled trials (RCTs) that studied the use of NIRAF vs. dissection with no intraoperative aids in thyroidectomy. Meta-analysis was performed using a random-effects model. Primary outcomes were postoperative hypocalcaemia and permanent hypoparathyroidism.

Eight RCTs were included in the final analysis, comprising 1620 patients. Meta-analysis revealed patients undergoing thyroidectomy using NIRAF had a reduced risk of both post-operative hypocalcaemia (OR 0.56, 95% CI: 0.36-0.89, p = 0.01) and persistent hypoparathyroidism (OR 0.44, 95% CI: 0.22-0.89, p = 0.02).

NIRAF use in thyroidectomy reduces the risk of post-operative hypocalcaemia and post-operative hypoparathyroidism.

Inadvertent devascularisation or removal of parathyroid glands (PT) during thyroidectomy necessitates their autotransplantation after Frozen section (FS). FS is time-consuming, tedious and expensive, disrupts the pathology department and is not universally available. This study aimed to determine the ratio of aspartate aminotransferase to lactate dehydrogenase (AST/LDH) of PT extracts to differentiate it from fat, thyroid, and lymph node (LN).

This prospective study was conducted on all patients planned for any thyroid or parathyroid surgery. Intra-operatively, a 2.5 × 2.5 × 2.5 mm3 of the devascularised or inadvertently removed PT was excised, minced in 2 mL normal saline and the supernatant fluid was sent to the standard lab for AST/LDH estimation. The minced tissue was sent for histopathological examination for confirmation. Thyroid, LN and fat samples were taken as controls and analysed similarly. Parathyroid adenoma (PTA) was analysed separately.

The mean AST/LDH ratios of PT (0.311 ± 0.176) were significantly higher than that of thyroid, fat and LN. A cut-off of ≥0.165 for PT had a sensitivity and specificity of 83.8% and 83.1% against thyroid tissue, 83.8% and 74% against fat, and 83.8% and 100% against LN. AST/LDH ratio of PTA was found to be 0.318.

AST/LDH ratio can be a simple, reliable, less labour-intensive method of identification of PT and can be a replacement for FS. The high specificity to differentiate an LN is clinically relevant in central compartment lymph node dissections with a higher probability of inadvertent removal or devascularisation of PT.

Accurate intraoperative identification of normal parathyroid glands (PTGs) is vital to avoid hypocalcemia post total thyroidectomy. Although ultrasonography (US) has been shown to identify normal PTGs, the significance of preoperative US PTG mapping in this context is not well studied. This study evaluated the impact of preoperative US PTG mapping on intraoperative identification of normal PTGs during total thyroidectomy.

The study involved 161 consecutive patients who underwent total thyroidectomy between January 2020 and June 2022. These included patients without preoperative US PTG mapping (group 1, n = 91) and those with the mapping (group 2, n = 70). Propensity score matching yielded 61 matched patients from each group. We developed a preoperative US PTG mapping technique combining US identification of normal PTGs with their localization on thyroid CT images. The intraoperative detectability of normal PTGs during thyroid surgery and detectability of normal PTGs by the preoperative US mapping were assessed by the number of PTGs identified per patient and by location.

In the matched cohort, group 2 demonstrated a higher median number of identified PTGs (3 vs. 2, p = 0.011), a greater proportion of patients with three or more identified PTGs (65.5% vs. 44.3%, p = 0.018), and a higher ratio of identified to expected PTGs (70.5% vs. 60.2%, p = 0.011) than group 1. In group 2, the median number of normal PTGs identified preoperatively was 3, with at least one identified in 95.7% of patients, two or more in 84.3%, three or more in 52.9%, and four or five in 24.3%.

Preoperative US PTG mapping identified two or more normal PTGs in the majority of adult patients undergoing total thyroidectomy. Those with preoperative mapping showed a higher number of intraoperatively identified normal PTGs, including inferior PTGs, compared to those without. This technique appears to enhance the intraoperative identification of normal PTGs, thereby potentially improving surgical outcomes in total thyroidectomy.

This study evaluates the clinical significance of nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for papillary thyroid carcinoma (PTC). The objective of this study was to assess the efficacy of nano-carbon suspension in enhancing parathyroid gland preservation, reducing postoperative complications, and improving surgical precision. A retrospective analysis on 219 PTC patients who underwent total thyroidectomy with cervical lymph node dissection between March 2014 and March 2018 was conducted. Patients were divided into two groups: an experimental group (n = 107) that received nano-carbon suspension and a control group (n = 112) that did not. Comparative analyses included demographics, surgical parameters, postoperative calcium and parathyroid hormone (PTH) levels, the number of dissected lymph nodes, and the incidence of complications. Baseline characteristics, including age, sex, and BMI, showed no statistically significant differences between the experimental and control groups. Postoperative calcium levels were significantly more stable in the experimental group, with median levels of 2.22 mmol/L on day 1 versus 2.06 mmol/L in the control group (P < 0.001), and 2.29 mmol/L at week 1 versus 2.22 mmol/L (P < 0.001). PTH levels were higher in the experimental group (35 pg/mL on day 1 versus 28 pg/mL, P < 0.001; 37 pg/mL at week 1 versus 30 pg/mL, P < 0.001). The experimental group had a greater median number of dissected lymph nodes (median 11.00 versus 7.00, P < 0.001) and a lower pathological parathyroid gland count (6.5% versus 23.2%, P < 0.001). Postoperative numbness and twitching were significantly reduced (4.7% versus 16.1%, P = 0.006), and the recurrence rate at 12 months was lower (4.7% versus 12.5%, P = 0.040). The use of Nano-carbon suspension in thyroidectomy and cervical lymph node dissection for PTC enhances parathyroid gland preservation, improves surgical precision, and reduces specific postoperative complications, supporting its standard adoption in thyroid cancer surgeries to optimize patient outcomes.

Postoperative hypoparathyroidism is a major complication of thyroidectomy, occurring when the parathyroid glands are inadvertently damaged during surgery. Although intraoperative images are rarely used to train artificial intelligence (AI) because of its complex nature, AI may be trained to intraoperatively detect parathyroid glands using various augmentation methods. The purpose of this study was to train an effective AI model to detect parathyroid glands during thyroidectomy.

Video clips of the parathyroid gland were collected during thyroid lobectomy procedures. Confirmed parathyroid images were used to train three types of datasets according to augmentation status: baseline, geometric transformation, and generative adversarial network-based image inpainting. The primary outcome was the average precision of the performance of AI in detecting parathyroid glands.

152 Fine-needle aspiration-confirmed parathyroid gland images were acquired from 150 patients who underwent unilateral lobectomy. The average precision of the AI model in detecting parathyroid glands based on baseline data was 77%. This performance was enhanced by applying both geometric transformation and image inpainting augmentation methods, with the geometric transformation data augmentation dataset showing a higher average precision (79%) than the image inpainting model (78.6%). When this model was subjected to external validation using a completely different thyroidectomy approach, the image inpainting method was more effective (46%) than both the geometric transformation (37%) and baseline (33%) methods.

This AI model was found to be an effective and generalizable tool in the intraoperative identification of parathyroid glands during thyroidectomy, especially when aided by appropriate augmentation methods. Additional studies comparing model performance and surgeon identification, however, are needed to assess the true clinical relevance of this AI model.

The added benefit of using near-infrared autofluorescence (NIRAF) during total thyroidectomy (TT) remains controversial. This study investigated whether or not NIRAF results in improved patient outcomes postoperatively.

We analyzed 1711 TT patients, reported in nine randomized controlled trials, following a systematic search of five databases. NIRAF was compared to the standard of care (naked eye with/without white light). Outcomes included parathyroid gland (PG) and calcium parameters and other clinical outcomes. For dichotomous outcomes, the log odds ratio (logOR) was calculated, and for continuous outcomes, the crude mean difference (MD) was measured. Sensitivity analysis was performed when heterogeneity was significant. The revised Cochrane risk of bias tool was used to assess the methodological quality.

Compared to the standard of care, the use of NIRAF was associated with a significant reduction in postoperative hypoparathyroidism [logOR=-0.31; 95% CI: -0.57: -0.05], inadvertent PG removal [logOR=-0.93; 95% CI: -1.60: -0.26], and postoperative hypocalcemia [logOR=-0.43 mmol/l; 95% CI: -0.77: -0.09]. It was also associated with significantly higher postoperative PTH levels [MD=4.78 pg/ml; 95% CI: 2.13: 7.43], PG identification rate [logOR=1.02; 95% CI: 0.31: 1.72], postoperative serum calcium [MD=0.05; 95% CI: 0.00: 0.09], and operative time [MD=9.38 min; 95% CI: 6.68: 12.09]. No difference was seen regarding PG autotransplantation, length of hospital stay, and hospitalization due to hypocalcemia. Seven trials had low risk and the remainder had some concerns.

NIRAF is superior to the naked eye in identifying all four PGs during TT. The reduced risk of postoperative hypoparathyroidism and hypocalcemia reflected this preservation value. However, it was not associated with a change in the length of hospital stay. Although rare, the readmission rate due to hypocalcemia was similar across both methods.

Background and Objectives: Secondary hyperparathyroidism (SHPT) poses a common condition among patients with chronic kidney disease (CKD) due to the chronic stimulation of the parathyroid glands as a result of persistently low calcium levels. As a first option for medical treatment, vitamin D receptor analogs (VDRAs) and calcimimetic agents are generally used. Apart from cinacalcet, which is orally taken, in recent years, another calcimimetic agent, etelcalcetide, is being administered intravenously during dialysis. Materials and Methods: In a 5-year retrospective study between 2018 and 2023, 52 patients undergoing dialysis were studied. The aim of this study is to highlight the possible effects and/or benefits that intravenously administered calcimimetic agents have on CKD patients. A total of 34 patients (65.4%) received cinacalcet and etelcalcetide while parathormone (PTH) and calcium serum levels were monitored on a monthly basis. Results: A total of 29 out of 33 patients (87.9%) that received treatment with etelcalcetide showed a significant decrease in PTH levels, which rose up to 57% compared to the initial values. None of the included patients needed to undergo parathyroidectomy (PTx) due to either extremely high and persistent PTH levels or severe side effects of the medications. It is generally strongly advised that parathyroidectomies should be performed by an expert surgical team. In recent years, a significant decrease in parathyroidectomies has been recorded globally, a fact that is mainly linked to the constantly wider use of new calcimimetic agents. This decrease in parathyroidectomies has resulted in an important decrease in complications occurring in cervical surgeries (e.g., perioperative hemorrhage and nerve damage). Conslusions: Despite the fact that these surgical complications cannot be easily compared to the pharmaceutical side effects, the recorded decrease in parathyroidectomies is considered to be notable, especially in cases of relapse where a difficult reoperation would be considered based on previously published guidelines.

The purpose of this study was to investigate the impact of autofluorescence technology on postoperative parathyroid function and short-term outcomes in patients undergoing thyroid surgery.

A total of 546 patients were included in the study, with 287 in the conventional treatment group and 259 in the autofluorescence group. Both groups underwent central lymph node dissection, which is known to affect parathyroid function. Short-term outcomes, including rates of postoperative hypocalcemia and parathyroid dysfunction, serum calcium and PTH levels on the first postoperative day, as well as the need for calcium supplementation, were analyzed. A multivariable analysis was also conducted to assess the impact of autofluorescence on postoperative parathyroid dysfunction, considering factors such as age, BMI, and preoperative calcium levels.

The autofluorescence group demonstrated significantly lower rates of postoperative hypocalcemia and parathyroid dysfunction compared to the conventional treatment group. The autofluorescence group also had better serum calcium and PTH levels on the first postoperative day, and a reduced need for calcium supplementation. Surprisingly, the use of autofluorescence technology did not prolong surgical time; instead, it led to a shorter hospitalization duration. The multivariable analysis showed that autofluorescence significantly reduced the risk of postoperative parathyroid dysfunction, while factors such as age, BMI, and preoperative calcium levels did not show a significant correlation.

This study provides evidence that autofluorescence technology can improve the preservation of parathyroid function during thyroid surgery, leading to better short-term outcomes and reduced postoperative complications. The findings highlight the potential of autofluorescence as a valuable tool in the management of parathyroid hypofunction. Further research and validation are needed to establish the routine use of autofluorescence technology in the thyroid.

This study aimed to assess the benefits and limitations of four intraoperative visualization of parathyroid gland (IVPG) strategies in the identification and functional protection of parathyroid glands (PGs).

We searched PubMed, the Cochrane Central Register of Controlled Trials, CNKI, EMBASE, Web of Science and Google Scholar databases until 30 June 2023. Four IVPG strategies were composed of the naked eyes (NE) and three imaging strategies: autofluorescence (AF), indocyanine green fluorescence (ICGF), and carbon nanoparticles (CN). We performed a pairwise meta-analysis (PMA) for direct comparisons and a Bayesian network meta-analysis (NMA) for indirect comparisons.

A total of 29 eligible studies were included. According to NMA and PMA, AF had significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, PG inadvertent resection, and PG auto-transplantation compared to NE, while had significantly higher rate of PG identification. CN showed significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, and PG inadvertent resection compared to NE in PMA and NMA. ICGF showed a significantly higher rate of PG auto-transplantation compared to NE in PMA and AF in NMA. According to SUCRA values, AF showed the best advantage in reducing the rate of postoperative hypocalcemia (0.85) and PG inadvertent resection (0.89), and increasing the rate of PG identification (0.80). CN had the greatest advantage in reducing the rate of postoperative hypoparathyroidism (0.95). ICGF ranked the highest in the rate of PG auto-transplantation (0.98).

Three imaging strategies demonstrate significant superiority over NE in the intraoperative PG identification and functional protection. AF is the best strategy in reducing the incidence of postoperative hypocalcemia, increasing the rate of PG identification, and reducing the rate of PG inadvertent resection and auto-transplantation. ICGF has great value in assessing PG viability, leading to the trend towards PG auto-transplantation. CN is the best strategy in reducing the incidence of postoperative hypoparathyroidism.

The surgical management of thyroid and parathyroid disease has evolved considerably since the era of Theodor Kocher. We review the current trends in thyroid and parathyroid surgery concerning robotic surgery for remote access, the use of parathyroid autofluorescence detection technology to aid in the prevention of hypocalcemia as well as the use of thermal ablation to target thyroid nodules in a minimally invasive way. We also discuss how artificial intelligence is being used to improve the workflow and diagnostics preoperatively as well as for intraoperative decision-making. We also discuss potential areas where future research may enhance outcomes.

Injury to the recurrent laryngeal nerve (RLN) and parathyroid glands (PGs) are the most common and serious complications during the transoral endoscopic thyroidectomy vestibular approach (TOETVA), and their exposure and protection are the most important factors affecting the operation time. Here, we report a novel anatomical landmark and surgical method to shorten the operative time and reduce the chance of injury to the RLN and PGs.

According to the different exposure methods of the RLN, patients were divided into the experimental group (from top to bottom, E-group) and the comparison group (from outside to inside, C-group), and 1:1 propensity score-matching (PSM) was performed. The demographics, operative data, postoperative data, and postoperative complications were analyzed by comparing the 2 groups.

After PSM, a total of 206 patients were included. Except for tumor size, there were no significant differences between the 2 groups in terms of sex, age, body mass index, presence of Hashimoto's thyroiditis, or extent of surgery. Compared with the C-group, the operative time, in minutes, of the E-group was significantly shorter (hemithyroidectomy with central neck dissection (CND), C = 111.81 ± 25.83 vs E = 100.52 ± 16.47, P = .002 and bilateral thyroidectomy with CND, C = 177.87 ± 36.61 vs E = 156.05 ± 25.60, P = .004), the exposure time, in minutes, of the RLN was reduced (hemithyroidectomy with CND, C = 23.31 ± 7.07 vs E = 11.41 ± 2.75, P < .001 and bilateral thyroidectomy with CND, C = 45.64 ± 14.84 vs E = 21.76 ± 5.57, P < .001). The rate of postoperative temporary PGs and RLN injuries were also reduced (transient hypoparathyroidism, C = 13% vs E = 4%, P = .023 and transient RLN palsy, C = 10% vs E = 2%, P = .017). In addition, the remaining parameters such as the amount of bleeding, number of lymph node metastases, postoperative hospital stay, visual analog scale pain score, recurrence rate, and other complication rates were not significantly different between the 2 groups.

It is safe and feasible to construct Thyroid-RLN Entry Triangle (Peng's Triangle) for PGs and RLN protection in TOETVA. It is beneficial to shorten the operation time and reduce postoperative complications, both worthy of clinical promotion.

This study was registered at the Chinese Clinical Trial Registry (UIN: ChiCTR2300067673, https://www.chictr.org.cn) in accordance with the World Medical Association's Declaration of Helsinki, 2013.

Postoperative hypoparathyroidism is a common complication following thyroidectomy, with the potential for significant morbidity and cost. While various techniques have been proposed for intraoperative parathyroid gland (PG) identification and preservation, indocyanine green (ICG) angiography has emerged as a promising method. In this retrospective study, patients who underwent total thyroidectomy with or without central neck dissection were evaluated for the utility of ICG angiography in identifying PGs and the correlation of ICG scores with postoperative parathyroid function.

ICG angiography was performed using a standardized protocol, and the degree of PG vascularization was assessed visually. A scoring system was employed based on ICG uptake intensity in PGs, as described in the literature. Pearson's correlation test examined the relationship between the total ICG score and percentage parathyroid hormone (PTH) gradient, postoperative calcium, and PTH levels. In addition, patients with at least one well-vascularized PG were also evaluated.

Twenty-two patients were included in the study. Significant positive correlations were found between the total ICG score and postoperative PTH levels (r=0.549, p=0.008), and a negative correlation with the percentage of PTH gradient (r=-0.504, p=0.01). However, six patients with well-vascularized PGs on ICG angiography still developed postoperative hypoparathyroidism.

ICG angiography offers a potential tool for evaluating PG vascularization during thyroidectomy and predicting the risk of postoperative hypoparathyroidism. However, its application should be used judiciously, and the technique should be improved for PG preservation. Further studies are warranted to better understand its benefits and limitations in thyroid surgery.

Preserving parathyroid glands in situ is crucial to avoid surgical hypoparathyroidism, but it is also one of the greatest challenges during thyroid surgery. Magnified endoscopic imaging has been proposed as a way to improve parathyroid preservation.

2,603 consecutive patients who underwent thyroid surgery at the First People's Hospital of Zunyi from January 2018 to July 2022 were screened. 1,355 patients were eligible, including 965 endoscopic and 390 open cases. Parathyroid hormone (PTH) loss levels and severe parathyroid injury rates were compared between endoscopic and open cases. Meanwhile, factors that contribute to parathyroid injuries were assessed, including surgical extent, tumor size, carbon nanoparticle guidance, and surgical proficiency.

PTH loss levels were similar between endoscopic and open cases (P = 0.440). The incidence of severe parathyroid injuries was also comparable (7.8% for endoscopic vs. 6.9% for open, P = 0.592). The endoscopic group had higher rates of autologous parathyroid transplantation (39.5% vs. 24.4%, P = 0.000), while accidental parathyroidectomy rates were similar (11.4% vs. 10.8%, P = 0.739). Among patients who received the same extent of thyroid surgeries, no significant difference was found in PTH loss levels and severe parathyroid injury rates, except for a higher risk of severe parathyroid injuries in endoscopic bilateral thyroidectomy (18.52% vs. 11.52%, P = 0.033).

Despite the magnified endoscopic imaging facilitating the identification of parathyroid tissues, endoscopic approaches are not superior to open ones for the in-situ preservation of parathyroid glands. For a bilateral thyroidectomy, open approaches are safer for parathyroid preservation.

Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.

To evaluate the clinical effect of subcapsular saline injection (SCASI) after total thyroidectomy.

A total of 77 patients who underwent total thyroidectomy in our hospital from January 2020 to December 2021 were selected and divided into the SCASI group (n = 43) and the non-SCASI group (n = 34). The general clinical data of the patients were collected, and serum parathyroid hormone (PTH) and serum calcium levels were determined preoperatively, on the 1st postoperative day, and at 1 and 6 months after the operation. These data were compared between groups.

There was no significant difference in postoperative complications between the two groups. The PTH and serum calcium levels in the SCASI group were significantly higher than those in the non-SCASI group on the 1st postoperative day (t = 2.340, 5.208, both P < 0.05), and the PTH levels in the SCASI group at 1 month after the operation were higher than those in the non-SCASI group (t = 2.141, P < 0.05). In addition, the proportion of transient and permanent hypoparathyroidism in the SCASI group was significantly decreased (χ2 = 3.920, 3.948, P < 0.05).

Total thyroidectomy requires high surgical precision, and SCASI can reduce the incidence of temporary and permanent hypoparathyroidism.

Parathyroid glands may be compromised during thyroid surgery which can lead to hypoparathyroidism and hypocalcemia. Identifying the parathyroid glands relies on the surgeon's experience and the only way to confirm their presence was through tissue biopsy. Near infrared autofluorescence technology offers an opportunity for real-time, non-invasive identification of the parathyroid glands.

We used a new research prototype (hANDY-I) developed by Optosurgical, LLC. It offers coaxial excitation light and a dual-Red Green Blue/Near Infrared sensor that guides anatomical landmarks and can aid in identification of parathyroid glands by showing a combined autofluorescence and colored image simultaneously.

We tested the imager during 23 thyroid surgery cases, where initial clinical feasibility data showed that out of 75 parathyroid glands inspected, 71 showed strong autofluorescence signal and were correctly identified (95% accuracy) by the imager.

The hANDY-I prototype demonstrated promising results in this feasibility study by aiding in real-time visualization of the parathyroid glands. However, further testing by conducting randomized clinical trials with a bigger sample size is required to study the effect on levels of hypoparathyroidism and hypocalcemia.

The usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology.

This was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons.

Overall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively.

This survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.

The parathyroid glands are important endocrine glands for maintaining calcium and phosphorus metabolism, and they are vulnerable to accidental injuries during thyroid cancer surgery. The aim of this retrospective study was to investigate the application of high-frequency ultrasound imaging for preoperative anatomical localization of the parathyroid glands in patients with thyroid cancer and to analyze the protective effect of this technique on the parathyroid glands and its effect on reducing postoperative complications.

A total of 165 patients who were operated for thyroid cancer in our hospital were included. The patients were assigned into two groups according to the time period of surgery: Control group, May 2018 to February 2021 (before the application of ultrasound localization of parathyroid in our hospital); PUS group, March 2021 to May 2022. In PUS group, preoperative ultrasound was used to determine the size and location of bilateral inferior parathyroid glands to help surgeons identify and protect the parathyroid glands during operation. We compared the preoperative ultrasound results with the intraoperative observations. Preoperative and first day postoperative serum calcium and PTH were measured in both groups.

Our preoperative parathyroid ultrasound identification technique has more than 90% accuracy (true positive rate) to confirm the location of parathyroid gland compared to intraoperative observations. Postoperative biochemical results showed a better Ca²⁺ [2.12(0.17) vs. 2.05(0.31), P=0.03] and PTH [27.48(14.88) vs. 23.27(16.58), P=0.005] levels at first day post-operation in PUS group compared to control group. We also found a reduced risk of at least one type of hypoparathyroidism after surgery in control group:26 cases (31.0%) vs. 41 cases (50.6%), p=0.016.

Ultrasound localization of the parathyroid glands can help in the localization, identification and in situ preservation of the parathyroid glands during thyroidectomy. It can effectively reduce the risk of hypoparathyroidism after thyroid surgery.

Medullary thyroid carcinoma (MTC) is a neoplasm originating from parafollicular C cells. MTC is a rare disease, but its prognosis is less favorable than that of well-differentiated thyroid cancers. To improve the prognosis of patients with MTC, early diagnosis and prompt therapeutic management are crucial. In the following paper, recent advances in laboratory and imaging diagnostics and also pharmacological and surgical therapies of MTC are discussed. Currently, a thriving direction of development for laboratory diagnostics is immunohistochemistry. The primary imaging modality in the diagnosis of MTC is the ultrasound, but opportunities for development are seen primarily in nuclear medicine techniques. Surgical management is the primary method of treating MTCs. There are numerous publications concerning the stratification of particular lymph node compartments for removal. With the introduction of more effective methods of intraoperative parathyroid identification, the complication rate of surgical treatment may be reduced. The currently used pharmacotherapy is characterized by high toxicity. Moreover, the main limitation of current pharmacotherapy is the development of drug resistance. Currently, there is ongoing research on the use of tyrosine kinase inhibitors (TKIs), highly specific RET inhibitors, radiotherapy and immunotherapy. These new therapies may improve the prognosis of patients with MTCs.

Thyroidectomy in paediatric patients is relatively uncommon. In this study, we reviewed our experience of thyroidectomy in children and identified risk factors associated with postoperative complications.

We performed a retrospective analysis of paediatric patients who had thyroidectomy in our institution between April 1995 and January 2021. Demographic data, preoperative cytological findings, indications of surgery, surgical complications and histological results were analysed.

A total of 87 paediatric patients with 92 thyroidectomy were identified. The indications for surgery were Graves' disease refractory to medical treatments (40.2%), benign thyroid nodules or multinodular goitre (26.4%), thyroid carcinoma (23.0%) and multiple endocrine neoplasm type 2A syndrome (10.3%). Patients presented with thyroid nodules or cervical lymph nodes had a 43.9% risk of malignancy. 66 total thyroidectomy were done with median operation time of 134 min(102-170), while 26 hemi-thyroidectomy were performed (Right side 12/92, Left side 14/92) with median operation time of 65 min(49-102). The median postoperative hospital stay was 2 days(1-4). Intraoperative neck dissection (p = 0.003), drain insertion (p = 0.001) and hypocalcaemia requiring medical treatment (p = 0.004) were associated with longer hospital stay. The median follow-up was 11.3 years (3.0-16.8). 32% patients had immediate postoperative hypocalcaemia and 8% patients had permanent hypoparathyroidism. Transient vocal cord palsy was found in 3 patients(3%) and all resolved within 5-month time upon reassessment direct laryngoscopy. The use of intraoperative recurrent laryngeal nerve monitoring was associated with less vocal cord palsy (p = 0.022). The median disease-free survival was 13.7 years(7.4-17.7) for patients operated for well-differentiated thyroid carcinoma(WDTC). amongst the 9 patients who had prophylactic total thyroidectomy for MEN2A syndrome, 44% were found to have medullary thyroid microcarcinomas on pathology.

Surgical management of paediatric thyroid disease can be complex. Postoperative hypocalcaemia and vocal cord palsy were usually transient after total thyroidectomy. The use of intraoperative recurrent laryngeal nerve monitoring had resulted in less vocal cord palsy. Long-term disease-free survival of patients with thyroid cancer had been achieved with multi-disciplinary management in our centre.

Retrospective Comparative Study; Level III.

Histologic assessments of papillary thyroid carcinoma are crucial for management of patients with the cancer as well as research on the cancer as papillary thyroid carcinoma has different histologic subtypes and many parameters which are essential in predicting the biological aggressiveness of the cancer. The histologic assessments should be guided by universally adopted protocols including World Health Organization (WHO) classification of endocrine tumors, International Collaboration on Cancer Reporting (ICCR) dataset, American Thyroid Association initial risk stratification for differentiated thyroid carcinomas and TNM stage groupings. The essential steps in histologic assessment involve the identification of characteristic features of papillary thyroid carcinoma, correct histologic subtyping, noting the number of carcinomas, measuring the size of the carcinoma, documenting the different aggressive histological parameters (mitotic activity, presence of tumor encapsulation/circumscription, lymphatic vessel invasion, blood vessel invasion, necrosis, extrathyroidal extension), resection margin status, associated pathology, presence of parathyroid gland, lymph node and distant metastases as well as synthesis of pathological stage based on the various clinical, macroscopic, and histological features.