Initial experience with ICG fluorescence during total thyroidectomy in Mexico: The postoperative hypocalcemia index decreases?

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Jorge Montalvo-Hernández, Doris M. Palacios, Carlos Javier Mata, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4427077/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Postoperative hypocalcemia is the most frequent complication of the total thyroidectomy. New techniques have recently emerged for the identification of the parathyroid glands, for example fluorescence with indocinaine green, which has been very well accepted by different groups of expert surgeons internationally. In this study we use it to assess the viability of the parathyroid glands after total thyroidectomy with the angiography image that it provides us. Methods : This is a cohort study including patients undergoing total thyroidectomy in 2020 using ICG fluorescence and they were evaluated for transient and permanent (>6 months) hypocalcemia postoperatively. In addition, results were compared with historical controls including patients treated by a low-volume thyroid surgeon (group A), and by a high-volume thyroid surgeon (group B). Several variables were included (number of auto-transplanted parathyroids, postoperative serum calcium leves, and symptoms of hypocalcemia) and analyzed between groups. The main aim of the study was to determine whether the use of ICG fluorescence associateswith a lower rate of postoperative hypocalcemia. Results : A total of 18 patients were operated using ICG fluorescence. Of them 14 (75%) cases were females and median age were 54 ±13.5 years. 29 patients were included in group A (operated by a low-volume thyroid surgeon) and 50 patients in group B (by a high-volume thyroid surgeon). Autotransplantation was no necessary in ICG group compared with 3 and 1 in the group A and B respectively. Thyroid cancer were confirmed in 58 (59%) of cases by histopathology. Postoperative calcium levels were higher in ICG fluorescence group compared with groups A and B since day-1 to 6 months of follow-up ( p =NS). Statistical analysis showed a significant difference in transient hypocalcemia and permanent hypoparathyroidism rates ( p=0.011 and p=0.002 respectively) when contrasted between groups. The sub-analysis showed that ICG-fluorescence did not reach adequate statistical significance compared to group of high-volume surgeon (B), both for transient and permanent hypocalcemia (p= 0.039 and p= 0.28 respectively). Conclusions : ICG fluorescence technique was associated with lower incidence of postoperative hypocalcemia specially when it is compared to low-volume thyroid surgeon. thyroidectomy fluorescence indocyanine green postoperative hypocalcemia parathyroid glands Figures Figure 1 BACKGROUND Total thyroidectomy (TTx) is the main surgical procedure for the treatment of malignant, and some benign thyroid diseases. 1 Although morbidity and mortality rates associated with this procedure have decreased in the last century, surgical complications represent an important negative impact on the patient’s quality of life. Common surgical complications of TTx include cervical hematoma, transient/permanent vocal cord palsy, and transient/permanent hypoparathyroidism, being the latter the most frequent with an incidence of 1.6–60% and 1–32%, respectively. 2–3 Postoperative hypoparathyroidism (PHP) is caused by a loss of parathyroid hormone (PTH) secretion as a result of operative ischemia of the parathyroid glands (PGs). Direct thermal lesion and mechanical injury of the PGs are both frequent causes of operative ischemia during thyroid surgery. Another cause of PHP is inadvertent resection of one or more PGs (partial or complete removal), usually because they were not visualized during surgery. 4–6 Many surgical strategies and techniques have been described to avoid permanent PHP such as the subcapsular dissection technique (to preserve vascular pedicle of the PGs), and auto transplantation of the PGs whenever it is required. 5–12 A relative novel technique is indocyanine green (ICG) fluorescence to PGs identify and preserve its viability by intraoperative angiography. ICG is a sterile, anionic, water-soluble, tricarbocyanine molecule use as dye for medical diagnostics. After IV injection it rapidly binds to plasmatic proteins and under near infra-red light (around 800 nanometers) becomes fluorescent. 11,15 This technique requires the intravenous (IV) administration of 1.25 or 2.5mg of ICG and a special imaging capture system allowing parathyroid gland identification, as well as, parathyroid gland viability assessment (vascular supply) before and after surgical manipulation of the glands during thyroid resection. More recently, surgeons’s experience correlates with less surgical complications after thyroid surgery, including less hypocalcemia. A threshold of > 50 thyroidectomies per year has been used to define the minimum volume of procedures that a surgeon should perform to improve patient outcomes 13–14 The main outcome of this study was to compare PGs’s associated complications (incidental parathyroidectomy, transient and permanent hypoparathyroidism) between a prospective group of patients surgically treated with TT using ICG fluorescence and historical controls of patients treated by a high-volume thyroid surgeon (> 25 thyroidectomy per year) or treated by a low volume experienced surgeon (< 25 thyroidectomy per year). Until today and based on the published scientific literature available regarding this technique, this is the first Mexican experience. PATIENTS AND METHODS This is a comparative study of a prospectively collected cohort of consecutive patients who underwent TT using ICG fluorescence (group of cases) for parathyroid gland identification and preservation from January to December 2019 in a third level hospital in Mexico. Selection criteria included patients older than 18 years with benign or malignant thyroid disease treated with TT with/without central/lateral neck lymph node dissection. All patients were informed of the potential adverse reactions of ICG use and consented to the use of this dye during the procedure. Serum calcium and albumin determinations were obtained during hospitalization (24 hours postoperative), 1 month and 6 months after hospital discharge. Patients with a thyroid volume resection less than TT, previous thyroid surgery or concomitant primary or secondary hyperparathyroidism were excluded from the study. Institutional Review Board of Ethics approved the study (DCAS-SSS-HCN-ENS-140-20). For the analysis, the following operative definitions were established: Transient hypocalcemia symptomatic hypocalcemia ( albumin-corrected serum calcium < 8.6 mg/dL) and the need for oral/intravenous calcium or vitamin D supplementation after thyroidectomy for a period less than 6 months after surgery. Permanent hypocalcemia albumin-corrected serum calcium < 8.6 mg/dL or the need for oral/intravenous calcium or vitamin D supplementation due to symptoms of hypocalcemia at 6 months after thyroidectomy. Inadvertent parathyroidectomy identification of one or more parathyroid glands in the surgical specimen in the final histopathological report. Auto-transplantation of parathyroid glands parathyroid tissue removed and auto-transplanted into the ipsilateral sternocleidomastoid muscle after confirming their histology by frozen section. ICG fluorescence technique After thyroid lobe mobilization and tracheoesophageal groove visualization, a 1 mL dose of ICG (VERDYE 2.5 mg/mL, Diagnostic Green) was administered to the patient through a peripheral intravenous (IV) access. Real-time images were obtained at two minutes after IV ICG administration using the Diagnostic Green IC-FLOW ™ device (Fig. 1 A) at 15 cm distance from the surgical wound to identify the parathyroid glands (Fig. 1 B). The decision to autotransplant one or more parathyroid glands was left to the discretion of the surgeon based on the fluorescence images obtained. Therefore, the parathyroid gland that was observed without fluorescence was excised and autotransplanted. This procedure was performed in the same manner for the contralateral side in each patient. For comparative analysis, two groups of historical control patients were included. All control patients were older than 18 years and treated with TT with/without neck lymph node dissection. Control A group were patients surgically treated by a low-volume thyroid surgeon (with training in neck surgery) and control B group were treated by a high-volume thyroid surgeon (endocrine surgeon). The main comparative outcomes included transient and permanent hypocalcemia, number of inadvertent resected parathyroid glands and the number of autotransplanted glands, based on the aforementioned operative definitions. Statistical description and inference were performed according to the natural scaling of all included variables. Proper statistical tests were employed for contrasting groups. Due to the multiple hypothesis tested between the groups of the study, any p value < 0.05 was considered statistically significant for a two-tailed hypothesis test. Mathematical data was analyzed with IBM ® SPSS © Statistics version 25 (SPSS © , Chicago, IL, USA). Data representation was elaborated with Numbers ® Apple © version 2.3. RESULTS A total of 97 patients were included in the study. Mean age (± standard deviation) of the entire cohort was 55.2 (±14.4), and gender distribution was 79 (81.4%) females and 18 (18.5%) males. Indications for surgical treatment were as follows: 35 (36%) indeterminate nodules (Bethesda III / IV), 31 (32%) preoperative diagnosis of malignant thyroid disease (Bethesda VI), 23 (23%) multinodular goiters (18 of them were compressive goiter), 3 (3%) suspicious of malignancy (Bethesda V), 3 (3%) non-diagnostic biopsied thyroid nodules (Bethesda I), and 2 (2%) uncontrolled hyperthyroidism cases. (Table 1) Final report of histopathology showed 58 ( 59%) cases of thyroid cancer. Surgical procedures were performed as follows: 77 (79%) patients required TT, 12 (12%) TT plus central compartment lymph node dissection (CCLND) and 8 (8%) TT + CCLND plus lateral compartment lymph node dissection. Eighteen (18.5%) patients were treated using the ICG fluorescence technique. Control group A were 29 (30%) patients treated between February 2017 to January 2019, and control group B were 50 (51.5%) patients treated between January 2018 to January 2019. Demographic, preoperative and operative features for each group are shown in Table 2. Adverse reactions were not observed in the ICG fluorescence technique group. Transient hypocalcemia were present in only 3 (16.6%) patients in the ICG group, in contrast to 15 (55%) in control group A and 22 (44%) in control group B ( p= 0.011). All these patients were supplemented with oral calcium carbonate. We realize a statistical subanalysis comparing results of ICG cases with control groups. The subanalysis showed a great significant difference when ICG-Fluorescence cases were compared with control group A ( p=0.009 ) and limited difference when were compared with control group B ( p=0.039 ), as shown in Table 3. Regarding permanent hypocalcemia, no cases were identified in ICG group in contrast to control groups (p=0.002). The statistical subanalysis that we made showed a great significant difference when the results of ICG group were compared with control group A, 0 vs 9 (31%) respectively (p=0.008). On the other hand, there was not statistical significance when compared with control group B (p=0.28), as shown in Table 4. As regards autotransplantation of parathyroid glands, no statistically significant differences were found between the groups studied (x 2 ; p=0.549 ) . Four parathyroid glands (in 4 cases) were removed and autotransplanted because of theirs ischemic appearance. No parathyroid gland was autotransplanted in the ICG group. Same results were observed in inadvertent parathyroidectomy (x 2 ; p= 0. 5 6 3) , histopathological diagnosis of malignant disease ( Fisher’s exact test ; p=0.81) and type of surgical procedure (x 2 ; p = 0.32). DISCUSSION Our data show that the ICG fluorescence technique is associated with a lower incidence of transient and permanent hypocalcemia mainly when they are compared to low-volume thyroid surgeon outcomes. Our results of the group with ICG showed a great statistical difference when compared with the results of the low-volume surgeon; however, when compared with the high-volume surgeon (group B), a slight statistical difference was observed with respect to the index of transient hypocalcemia, and even the results of permanent hypocalcemia were similar without reaching statistical significance (p = 0.28). We infer that these results obtained are due to the difference in experience between a high-volume and a low-volume thyroid surgeon. In the same way, in a prospective study, Papavramidis 16 et al, did not find a statistical difference in the incidence of postoperative hypocalcemia ( r = 0.156; p = .233) nor hypoparathyroidism (measuring Parathormone serum levels) ( r = 0.009; p = .948) when they used ICG fluorescence, and they emphasized that the 3 participating surgeons were experts in thyroid surgery (> 50 thyroidectomies/year). Surgeon’s experience has demonstrated on global medical literature that it not only reduce the risk of hypocalcemia, but also eventually the cost of a conventional total thyroidectomy. 17 The definition of postoperative hypoparathyrodism is a very broad topic, since more than 20 different definitions were found in recent publications by Harsløf T and mentioned in the 2019 systematic review. 18 The complications of transient and permanent hypocalcemia were defined in our study by biochemical criteria (blood calcium level below normal) and clinical criteria (symptoms related to hypocalcemia and/or the need to take an oral calcium supplement), since the PTH level was not routinely measured in all our patients. Therefore, it is important to note that the definition of postoperative hypocalcemia (hypoparathyroidism) may influence our incidence of postoperative hypocalcemia and differ from other published results. Thyroid malignancy and central neck dissection are well-known factors that are associated with transient and permanent hypocalcemia, however both were presented in a similar distribution in each one of ours studies groups (p = 0.20 and p = 0.41 respectively). Because of that, we included all these cases in the statistical analysis minimizing the risk of bias. On the other hand, Zaidi et al 19 showed their results with a higher identification rate of the parathyroid glands using ICG fluorescence (between 1 and 20 minutes after IV ICG administration) in a cohort of patients with well-differentiated or Graves' disease. Furthermore, Yu et al 20 in their comparative study of patients surgically treated for papillary thyroid carcinoma with the BABA robotic approach showed a statistically significant lower rate of incidental parathyroidectomy in the ICG fluorescence group (0/22) in contrast to the control group ( 7 /44). In our initial experience with the use of ICG fluorescence, we evaluated the parathyroid glands at the end of the mobilization of each thyroid lobe, which may be the reason that we did not find a statistical difference in the incidence of inadvertent resection of parathyroid glands ( p = 0.563) nor in the number of them identified in the surgical field. Currently we look for the parathyroids with ICG prior to the complete mobilization of each thyroid lobe, in such a way that we can perfectly observe the main vascularity of each one (vascular anatomy) and also observe that parathyroid in subcapsular position. In this way we optimize the dissection of the gland by preserving its vascularity (post-dissection viability) and avoiding its inadvertent resection. There are limitations in the methodology of our study and it is important to mention them: it is not randomized, the number of patients included in the study are low (specially in the case group), and the historical controls may be susceptible to selection bias. Our study included a single case group with thyroidectomies performed by a high-volume surgeon, so our inferences and conclusions are limited to the lack of results from the use of fluorescence in low-volume surgeons. By including this additional group, we could find out if there is a real role for ICG in low-volume surgeons, since most of the studies carried out in this regard have been carried out in groups of expert surgeons and the results may not be evident. Finally, this is our learning curve in the use of ICG fluorescence, so results may not show benefits until we reach an experienced and consistent use of the technique. However, we hope that this technique may have a greater impact in hospitals with trainee residents and less experienced surgeons (such as recent graduates), especially for location, tissue confirmation, and proper dissection of the parathyroid glands (by showing their arterial supply with fluorescence). CONCLUSIONS Our results demonstrated that the use of fluorescence with ICG dye reduces the incidence of transient and permanent hypocalcemia, however it does not reach statistical significance in comparison with the results of more experienced surgeons (high-volume thyroid surgeon). These results should be evaluated by prospective randomized studies. Declarations Conflict of interest: Informed consent was obtained from all individual participants included in the study. Disclosure Statement: No competing financial interest exists. Funding information: No funding was received for this article, however we thank the Deputy Director of Health Services of Petróleos Mexicanos for providing the means to perform the surgical procedures on the patients. Institutional Review Board of Ethics approved the study (DCAS-SSS-HCN-ENS-140-20). Author Contribution Jorge Montalvo was the main surgeon in every surgical cases.Carlos J. Mata, Eduardo Jordan, Jorge Boy, Ximena Morán assisted in the surgeries.All autores review the manuscript. References Zhou HY, He JC, McHenry CR. Inadvertent parathyroidectomy: incidence, risk factors and ouctomes. J Surge Res. 2016;205:70–5. Edafe O, Antakia R, Laskar N, Uttley L, Balasubramanian SP. Systematic review and meta-analysis of predictors of post-thyroidectomy hipocalcaemia. Br J Surg. 2014;101:307–20. Fama F, Cicciu M, Polito F, Cascio A, Gioffre.Florio M, et al. Parathyroid autotrasplantation during thyroid surgery: a novel technique using a cell culture nutrient solution. World J Surg. 2017;41:457–63. Asari R, Passler C, Kaczirek K, Scheuba C, Niederle B. Hypoparathyroidism after total thyroidectomy: a prospective study. Arch Surg. 2008;143:132–7. (Discussion 8). Lorente-Poch L, Sancho J, Munoz JL, Gallego-Otaegui L, Mar- tinez-Ruiz C, Sitges-Serra A. Failure of fragmented parathyroid gland autotransplantation to prevent permanent hypoparathyroidism after total thyroidectomy. Langenbeck’s Arch Surg. 2017;402:281–7. Shaha AR, Jaffe BM. Parathyroid preservation during thyroid surgery. Am J Otolaryngol. 1998;19:113–7. Lorente-Poch L, Sancho JJ, Ruiz S, Sitges-Serra A. Importance of in situ preservation of parathyroid glands during total thyroidectomy. Br J Surg. 2015;102:359–67. Herrera M, Grant C, van Heerden JA, Fitzpatrick LA. Parathyroid autotransplantation. Arch Surg. 1992;127:825–9. (Dis- cussion 9–30). Sierra M, Herrera MF, Herrero B, Jimenez F, Sepulveda J, et al. Prospective biochemical and scintigraphic evaluation of 123 autografted normal parathyroid glands in patients undergoing thyroid operations. Surgery. 1998;124:1005–10. Wells SA Jr, Gunnells JC, Shelburne JD, Schneider AB, Sherwood LM. Transplantation of the parathyroid glands in man: clinical indications and results. Surgery. 1975;78:34–44. Gioux S, Choi HS, Frangioni JV. Image-guided surgery using invisible near-infrared light: Fundamentals of clinical translation. Mol Imaging. 2010;9:237–55. Chand G, Agarwal S, Mishra A, et al. The impact of uniform capsular dissection technique of total thyroidectomy on postoperative complications: an experience of more than 1000 total thyroidectomies from and endocrine surgery training center in North India. Indian J Endocrinol Metab. 2018;22(3):362–7. Chowdury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94(2):145–61. Adam MA, Thomas S, Youngwirth L, et al. Is there a minimum number of thyroidectomies a surgeon should perform to optimize patient outcomes? Ann Surg. 2017;265(2):402–7. Boni L, David G, Mangano A, et al. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc. 2015;29(7):2046–55. Papavramidis TS, Anagnostis P, Chorti A, Pliakos I, Panidis S, Koutsoumparis D, Michalopoulos A. Do Near-Infrared Intra-Operative Findings Obtained Using Indocyanine Green Correlate with Post-Thyroidectomy Parathyroid Function? the Icgpredict Study. Endocr Pract. 2020;26(9):967–973. 10.4158/EP-2020-0119 . PMID: 33471701. Patel N, Scott-Coombes D. Impact of surgical volume and surgical outcome assessing registers on the quality of thyroid surgery. Best Pract Res Clin Endocrinol Metab. 2019;33(4):101317. 10.1016/j.beem.2019.101317 . Epub 2019 Aug 31. PMID: 31526606. Harsløf T, Rolighed L, Rejnmark L. Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review. Endocrine. 2019;64:176–83. Zaidi N, Bucak E, Yazici P, Soundararajan S, Okoh A, Yigitbas H, Dural C, Berber E. The feasibility of indocyanine green fluorescence imaging for identifiying and assessing the perfusion of parathyroid glans during total thyroidectomy. J Surg Oncol. 2016;113(7):775–8. Yu HW, Chung JW, Yi JW, Song RY, Lee JH, Kwon H, Kim SJ, Chai YJ, Choi JY, Lee KE. Intraoperative localization of the parathyroid glands with indocyanine green and Firefly® technology during BABA robotic thyroidectomy. Surg Endosc J. 2017;31(7):3020–7. Tables Table 1. Surgical indications for total thyroidectomy TOTAL THYROIDECTOMY INDICATIONS (n=97) # cases (%) indeterminate nodules (*Bethesda III y IV) 35 (36) Thyroid cancer (Bethesda VI) 31 (32) Multinodular goiter 23 (23) Suspicious of malignancy (Bethesda V) 3 (3) Nondiagnostic or unsatisfactory (Bethesda I) 3 (3) Hyperparathyroidism 2 (2) *Diagnostic categories of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) Table 2. Demographic, preoperative and operative features for ICG fluorescence treated patients, controls treated by high-volume thyroid surgeon and by a low-volume thyroid surgeon. ICG fluorescence group (n=18) Low-volume thyroid surgeon , A group (n= 29 ) High-volume thyroid surgeon , B group (n= 50 ) p value Gender 0.21 Female n(%) 14 (75%) 22 (76%) 43 (86%) Male n(%) 4 (25%) 7 (24%) 7 (14%) Age (years) 54 ± 13.5 56 ± 12.1 57.5 ± 14.6 0.76 Surgical procedure 0.41 Total thyroidectomy n(%) 13 (72%) 25 (86%) 39 (78%) TT + CCLND n(%) 4 (22%) 4 (14%) 4 (8%) TT + CCLND + LCLND n(%) 1 (5.5%) 0 (0%) 7 (14%) Operative time (min) 110 ± 28.5 130 ± 42.8 120 ± 53.7 0.06 Blood loss (mL) 30 ± 36.6 75 ± 47.9 35 ± 41.3 0.001* Hospital stay 1.5 2.0 1.5 NS Autotransplantation of parathryoid tissue 0 3 1 NS Calcium Level at 24h (mg/ml) 8.6 (7.7-9.3) 8.1 (7.2-9.0) 8.4 (6.9-9.8) NS 1 month (mg/ml) 9.4 (8.7-10) 8.8 (6.7-9.8) 9.2 (8.2-9.9) NS 6 month (mg/ml) 9.2 (8.8-9.7) 9.0 (6.5-11.1) 9.1 (7.3-10.0) NS Histopathological report 0.20 Malignant disease 9 (50%) 22 (75%) 27 (54%) Benign disease 9 (50%) 7 (24%) 23 (46%) *Statistically significant TN: thyroid nodule, TT: total thyroidectomy, CCLND: central compartment lymph node dissection, LCLND: Uni- lateral compartment lymph node dissection . Table 3. TRANSIENT HYPOCALCEMIA using ICG-Fluorescence. Comparative results with Low- and High thyroid surgeon (A and B respectively) 3.A Transient Hypocalcemia ICG-Fluorescence versus Low-volume thyroid surgeon (n=47) No Yes ICG-Fluorescence cases 15 (84%) 3 (16%) Control group A (low volume thyroid surgeon) 13 (45%) 16 (55%) p= 0.009 3.B Transient Hypocalcemia ICG-Fluorescence versus High-volume thyroid surgeon (n=68) No Yes ICG-Fluorescence cases 15 (84%) 3 (16%) Control group B (high volume thyroid surgeon) 28 (56%) 22 (44%) p= 0.0 39 Table 4. PERMANENT HYPOCALCEMIA using ICG-Fluorescence. Comparative results with Low- and High thyroid surgeon (A and B respectively) 4.A Permanent Hypocalcemia ICG-Fluorescence versus Low-volume thyroid surgeon (n=47) No Yes ICG-Fluorescence cases 18 (100) 0 (∅) Control group A (low volume thyroid surgeon) 20 (69) 9 (31) p= 0.00 8 4.B Permanent Hypocalcemia ICG-Fluorescence versus High-volume thyroid surgeon (n=68) No Yes ICG-Fluorescence cases 18 (100) 0 (∅) Control group B (High volume thyroid surgeon) 47 (94%) 3 (6%) p= 0. 288 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4427077","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308484601,"identity":"f1f64ccc-a7f9-4dea-8582-8f352bb8f478","order_by":0,"name":"Jorge Montalvo-Hernández","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYBACxgY4kxnIrGBgMCBaCw+YeYYILXAA1sLYRoQW5vbexy8+5tjk2bMfbJP4OO+wvDl78wGGHxXbcDus57iZ5cxtacU8PIltkjO3HTbc2XMsgbHnzG3cWmaksRnzbjuc2MOQ2AxiMG64kWPAzNhGQMtfkBb+h0Atcw7bE6OF+TEjSItEYuNj3obDiYS19BxjY+zdlpbYc+Nh48MZx9KTN5w5lnAQn18M29uYP/zcZpPY3p984MCHGmvbDcebDz74UYFHSwMDmwQSvxlMHsCpHgjkgVHzAYlfh0/xKBgFo2AUjFAAAEm4X9va3sGyAAAAAElFTkSuQmCC","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":true,"prefix":"","firstName":"Jorge","middleName":"","lastName":"Montalvo-Hernández","suffix":""},{"id":308484603,"identity":"4d078d24-7a55-4c71-8646-df41c33aac13","order_by":1,"name":"Doris M. Palacios","email":"","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":false,"prefix":"","firstName":"Doris","middleName":"M.","lastName":"Palacios","suffix":""},{"id":308484605,"identity":"0e983ad6-cadf-4d38-a08d-2be948886631","order_by":2,"name":"Carlos Javier Mata","email":"","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Javier","lastName":"Mata","suffix":""},{"id":308484606,"identity":"00f93a6a-0986-42d9-a292-04aab49c4a18","order_by":3,"name":"Eduardo Jordan","email":"","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":false,"prefix":"","firstName":"Eduardo","middleName":"","lastName":"Jordan","suffix":""},{"id":308484607,"identity":"7b09e917-067b-43b8-969a-c23234c55432","order_by":4,"name":"Jorge Boy-Serratos","email":"","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"","lastName":"Boy-Serratos","suffix":""},{"id":308484609,"identity":"fd81a214-1d52-4810-b83f-0c119dcccd39","order_by":5,"name":"Diana Ximena Morán","email":"","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":false,"prefix":"","firstName":"Diana","middleName":"Ximena","lastName":"Morán","suffix":""},{"id":308484615,"identity":"84197bc2-e4d1-4516-88cd-df59130c1f2a","order_by":6,"name":"José Alfredo Álvarez-López","email":"","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Alfredo","lastName":"Álvarez-López","suffix":""},{"id":308484616,"identity":"1785759f-9493-4729-8e4b-f12d30aaa70c","order_by":7,"name":"José German Carrasco-Tobón","email":"","orcid":"","institution":"Hospital Central Norte PEMEX","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"German","lastName":"Carrasco-Tobón","suffix":""}],"badges":[],"createdAt":"2024-05-15 19:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4427077/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4427077/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57874182,"identity":"a11198d7-2717-489a-a5a2-dbe57c1d4e26","added_by":"auto","created_at":"2024-06-06 18:45:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1755885,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Diagnostic Green IC-FLOW\u003csup\u003eTM\u003c/sup\u003e device (Figure 1A) at 15 cm distance from the surgical wound. (B) Highly fluorescent (bright) parathyroid gland.\u003c/p\u003e","description":"","filename":"Figure1..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4427077/v1/f60fed29ed5221105b01b6c9.jpg"},{"id":61009549,"identity":"070f8256-e66d-4901-a16d-65aa7326fe95","added_by":"auto","created_at":"2024-07-24 14:19:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2262328,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4427077/v1/a18f34bf-2616-4b84-a23e-633c56db022c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Initial experience with ICG fluorescence during total thyroidectomy in Mexico: The postoperative hypocalcemia index decreases?","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eTotal thyroidectomy (TTx) is the main surgical procedure for the treatment of malignant, and some benign thyroid diseases.\u003csup\u003e1\u003c/sup\u003e Although morbidity and mortality rates associated with this procedure have decreased in the last century, surgical complications represent an important negative impact on the patient\u0026rsquo;s quality of life. Common surgical complications of TTx include cervical hematoma, transient/permanent vocal cord palsy, and transient/permanent hypoparathyroidism, being the latter the most frequent with an incidence of 1.6\u0026ndash;60% and 1\u0026ndash;32%, respectively.\u003csup\u003e2\u0026ndash;3\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePostoperative hypoparathyroidism (PHP) is caused by a loss of parathyroid hormone (PTH) secretion as a result of operative ischemia of the parathyroid glands (PGs). Direct thermal lesion and mechanical injury of the PGs are both frequent causes of operative ischemia during thyroid surgery. Another cause of PHP is inadvertent resection of one or more PGs (partial or complete removal), usually because they were not visualized during surgery.\u003csup\u003e4\u0026ndash;6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMany surgical strategies and techniques have been described to avoid permanent PHP such as the subcapsular dissection technique (to preserve vascular pedicle of the PGs), and auto transplantation of the PGs whenever it is required.\u003csup\u003e5\u0026ndash;12\u003c/sup\u003e A relative novel technique is indocyanine green (ICG) fluorescence to PGs identify and preserve its viability by intraoperative angiography. ICG is a sterile, anionic, water-soluble, tricarbocyanine molecule use as dye for medical diagnostics. After IV injection it rapidly binds to plasmatic proteins and under near infra-red light (around 800 nanometers) becomes fluorescent.\u003csup\u003e11,15\u003c/sup\u003e This technique requires the intravenous (IV) administration of 1.25 or 2.5mg of ICG and a special imaging capture system allowing parathyroid gland identification, as well as, parathyroid gland viability assessment (vascular supply) before and after surgical manipulation of the glands during thyroid resection.\u003c/p\u003e \u003cp\u003eMore recently, surgeons\u0026rsquo;s experience correlates with less surgical complications after thyroid surgery, including less hypocalcemia. A threshold of \u0026gt;\u0026thinsp;50 thyroidectomies per year has been used to define the minimum volume of procedures that a surgeon should perform to improve patient outcomes \u003csup\u003e13\u0026ndash;14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe main outcome of this study was to compare PGs\u0026rsquo;s associated complications (incidental parathyroidectomy, transient and permanent hypoparathyroidism) between a prospective group of patients surgically treated with TT using ICG fluorescence and historical controls of patients treated by a high-volume thyroid surgeon (\u0026gt;\u0026thinsp;25 thyroidectomy per year) or treated by a low volume experienced surgeon (\u0026lt;\u0026thinsp;25 thyroidectomy per year). Until today and based on the published scientific literature available regarding this technique, this is the first Mexican experience.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003eThis is a comparative study of a prospectively collected cohort of consecutive patients who underwent TT using ICG fluorescence (group of cases) for parathyroid gland identification and preservation from January to December 2019 in a third level hospital in Mexico. Selection criteria included patients older than 18 years with benign or malignant thyroid disease treated with TT with/without central/lateral neck lymph node dissection. All patients were informed of the potential adverse reactions of ICG use and consented to the use of this dye during the procedure. Serum calcium and albumin determinations were obtained during hospitalization (24 hours postoperative), 1 month and 6 months after hospital discharge. Patients with a thyroid volume resection less than TT, previous thyroid surgery or concomitant primary or secondary hyperparathyroidism were excluded from the study. Institutional Review Board of Ethics approved the study (DCAS-SSS-HCN-ENS-140-20).\u003c/p\u003e \u003cp\u003eFor the analysis, the following operative definitions were established:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTransient hypocalcemia\u003c/strong\u003e \u003cp\u003esymptomatic hypocalcemia \u003cem\u003e(\u003c/em\u003ealbumin-corrected serum calcium\u0026thinsp;\u0026lt;\u0026thinsp;8.6 mg/dL) \u003cem\u003eand\u003c/em\u003e the need for oral/intravenous calcium or vitamin D supplementation after thyroidectomy for a period less than 6 months after surgery.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePermanent hypocalcemia\u003c/strong\u003e \u003cp\u003ealbumin-corrected serum calcium\u0026thinsp;\u0026lt;\u0026thinsp;8.6 mg/dL or the need for oral/intravenous calcium or vitamin D supplementation due to symptoms of hypocalcemia at 6 months after thyroidectomy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInadvertent parathyroidectomy\u003c/strong\u003e \u003cp\u003eidentification of one or more parathyroid glands in the surgical specimen in the final histopathological report.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAuto-transplantation of parathyroid glands\u003c/strong\u003e \u003cp\u003eparathyroid tissue removed and auto-transplanted into the ipsilateral sternocleidomastoid muscle after confirming their histology by frozen section.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eICG fluorescence technique\u003c/h2\u003e \u003cp\u003eAfter thyroid lobe mobilization and tracheoesophageal groove visualization, a 1 mL dose of ICG (VERDYE 2.5 mg/mL, Diagnostic Green) was administered to the patient through a peripheral intravenous (IV) access. Real-time images were obtained at two minutes after IV ICG administration using the Diagnostic Green IC-FLOW\u003csup\u003e\u0026trade;\u003c/sup\u003e device (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA) at 15 cm distance from the surgical wound to identify the parathyroid glands (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The decision to autotransplant one or more parathyroid glands was left to the discretion of the surgeon based on the fluorescence images obtained. Therefore, the parathyroid gland that was observed without fluorescence was excised and autotransplanted. This procedure was performed in the same manner for the contralateral side in each patient.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor comparative analysis, two groups of historical control patients were included. All control patients were older than 18 years and treated with TT with/without neck lymph node dissection. Control A group were patients surgically treated by a low-volume thyroid surgeon (with training in neck surgery) and control B group were treated by a high-volume thyroid surgeon (endocrine surgeon).\u003c/p\u003e \u003cp\u003eThe main comparative outcomes included transient and permanent hypocalcemia, number of inadvertent resected parathyroid glands and the number of autotransplanted glands, based on the aforementioned operative definitions.\u003c/p\u003e \u003cp\u003eStatistical description and inference were performed according to the natural scaling of all included variables. Proper statistical tests were employed for contrasting groups. Due to the multiple hypothesis tested between the groups of the study, any \u003cem\u003ep\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for a two-tailed hypothesis test. Mathematical data was analyzed with IBM\u003csup\u003e\u0026reg;\u003c/sup\u003e SPSS\u003csup\u003e\u0026copy;\u003c/sup\u003e Statistics version 25 (SPSS\u003csup\u003e\u0026copy;\u003c/sup\u003e, Chicago, IL, USA). Data representation was elaborated with Numbers\u003csup\u003e\u0026reg;\u003c/sup\u003e Apple\u003csup\u003e\u0026copy;\u003c/sup\u003e version 2.3.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 97 patients were included in the study. Mean age (\u0026plusmn; standard deviation) of the entire cohort was 55.2 (\u0026plusmn;14.4), and gender distribution was 79 (81.4%) females and 18 (18.5%) males. Indications for surgical treatment were as follows: 35 (36%) indeterminate nodules (Bethesda III / IV), 31 (32%) preoperative diagnosis of malignant thyroid disease (Bethesda VI), 23 (23%) multinodular goiters (18 of them were compressive goiter), 3 (3%) suspicious of malignancy (Bethesda V), 3 (3%) non-diagnostic biopsied thyroid nodules (Bethesda I), and 2 (2%) uncontrolled hyperthyroidism cases. (Table 1) Final report of histopathology showed 58 ( 59%) cases of thyroid cancer.\u003c/p\u003e\n\u003cp\u003eSurgical procedures were performed as follows: 77 (79%) patients required TT, 12 (12%) TT plus central compartment lymph node dissection (CCLND) and 8 (8%) TT + CCLND plus lateral compartment lymph node dissection.\u003c/p\u003e\n\u003cp\u003eEighteen (18.5%) patients were treated using the ICG fluorescence technique. Control group A were 29 (30%) patients treated between February 2017 to January 2019, and control group B were 50 (51.5%) patients treated between January 2018 to January 2019. Demographic, preoperative and operative features for each group are shown in Table 2. Adverse reactions were not observed in the ICG fluorescence technique group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTransient\u0026nbsp;hypocalcemia were present in only 3 (16.6%) patients in the\u0026nbsp;ICG\u0026nbsp;group, in contrast to 15 (55%) in control group A and 22 (44%) in control group B\u0026nbsp;(\u003cem\u003ep=\u003c/em\u003e0.011).\u0026nbsp;All these patients were supplemented with oral calcium carbonate.\u0026nbsp;We realize a statistical\u0026nbsp;subanalysis\u0026nbsp;comparing\u0026nbsp;results\u0026nbsp;of ICG cases with control groups.\u0026nbsp;The subanalysis showed a\u0026nbsp;great\u0026nbsp;significant difference when ICG-Fluorescence cases were compared with control group A (\u003cem\u003ep=0.009\u003c/em\u003e)\u0026nbsp;and\u0026nbsp;limited difference when were compared with\u0026nbsp;control group B (\u003cem\u003ep=0.039\u003c/em\u003e), as shown in Table 3.\u003c/p\u003e\n\u003cp\u003eRegarding permanent hypocalcemia, no cases were identified in ICG group in contrast to control groups (p=0.002). The statistical subanalysis that we made showed a great significant difference when the results of ICG group were compared with control group A, 0 vs 9 (31%) respectively (p=0.008). On the other hand, there was not statistical significance when compared with control group B (p=0.28), as shown in Table 4.\u003c/p\u003e\n\u003cp\u003eAs regards autotransplantation of parathyroid glands, no statistically significant differences were found between the groups studied\u0026nbsp;(x\u003csup\u003e2\u003c/sup\u003e;\u003cem\u003e\u0026nbsp;p=0.549\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e Four parathyroid glands (in 4 cases) were removed and autotransplanted because of theirs ischemic appearance. No parathyroid gland was autotransplanted in the ICG group. Same results were observed in inadvertent parathyroidectomy (x\u003csup\u003e2\u003c/sup\u003e; \u003cem\u003ep= 0.\u003c/em\u003e\u003cem\u003e5\u003c/em\u003e\u003cem\u003e6\u003c/em\u003e\u003cem\u003e3)\u003c/em\u003e, histopathological diagnosis of malignant disease \u003cem\u003e(\u003c/em\u003eFisher\u0026rsquo;s exact test\u003cem\u003e; p=0.81)\u003c/em\u003e and type of surgical procedure (x\u003csup\u003e2\u003c/sup\u003e; \u003cem\u003ep = 0.32).\u003c/em\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur data show that the ICG fluorescence technique is associated with a lower incidence of transient and permanent hypocalcemia mainly when they are compared to low-volume thyroid surgeon outcomes.\u003c/p\u003e \u003cp\u003eOur results of the group with ICG showed a great statistical difference when compared with the results of the low-volume surgeon; however, when compared with the high-volume surgeon (group B), a slight statistical difference was observed with respect to the index of transient hypocalcemia, and even the results of permanent hypocalcemia were similar without reaching statistical significance (p\u0026thinsp;=\u0026thinsp;0.28). We infer that these results obtained are due to the difference in experience between a high-volume and a low-volume thyroid surgeon. In the same way, in a prospective study, Papavramidis\u003csup\u003e16\u003c/sup\u003e et al, did not find a statistical difference in the incidence of postoperative hypocalcemia (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.156; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.233) nor hypoparathyroidism (measuring Parathormone serum levels) (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009; \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.948) when they used ICG fluorescence, and they emphasized that the 3 participating surgeons were experts in thyroid surgery (\u0026gt;\u0026thinsp;50 thyroidectomies/year). Surgeon\u0026rsquo;s experience has demonstrated on global medical literature that it not only reduce the risk of hypocalcemia, but also eventually the cost of a conventional total thyroidectomy.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe definition of postoperative hypoparathyrodism is a very broad topic, since more than 20 different definitions were found in recent publications by Harsl\u0026oslash;f T and mentioned in the 2019 systematic review.\u003csup\u003e18\u003c/sup\u003e The complications of transient and permanent hypocalcemia were defined in our study by biochemical criteria (blood calcium level below normal) and clinical criteria (symptoms related to hypocalcemia and/or the need to take an oral calcium supplement), since the PTH level was not routinely measured in all our patients. Therefore, it is important to note that the definition of postoperative hypocalcemia (hypoparathyroidism) may influence our incidence of postoperative hypocalcemia and differ from other published results.\u003c/p\u003e \u003cp\u003eThyroid malignancy and central neck dissection are well-known factors that are associated with transient and permanent hypocalcemia, however both were presented in a similar distribution in each one of ours studies groups \u003cem\u003e(p\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.20 and \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.41 respectively). Because of that, we included all these cases in the statistical analysis minimizing the risk of bias.\u003c/p\u003e \u003cp\u003eOn the other hand, Zaidi et al\u003csup\u003e19\u003c/sup\u003e showed their results with a higher identification rate of the parathyroid glands using ICG fluorescence (between 1 and 20 minutes after IV ICG administration) in a cohort of patients with well-differentiated or Graves' disease. Furthermore, Yu et al\u003csup\u003e20\u003c/sup\u003e in their comparative study of patients surgically treated for papillary thyroid carcinoma with the BABA robotic approach showed a statistically significant lower rate of incidental parathyroidectomy in the ICG fluorescence group (0/22) in contrast to the control group ( 7 /44). In our initial experience with the use of ICG fluorescence, we evaluated the parathyroid glands at the end of the mobilization of each thyroid lobe, which may be the reason that we did not find a statistical difference in the incidence of inadvertent resection of parathyroid glands ( p\u0026thinsp;=\u0026thinsp;0.563) nor in the number of them identified in the surgical field. Currently we look for the parathyroids with ICG prior to the complete mobilization of each thyroid lobe, in such a way that we can perfectly observe the main vascularity of each one (vascular anatomy) and also observe that parathyroid in subcapsular position. In this way we optimize the dissection of the gland by preserving its vascularity (post-dissection viability) and avoiding its inadvertent resection.\u003c/p\u003e \u003cp\u003eThere are limitations in the methodology of our study and it is important to mention them: it is not randomized, the number of patients included in the study are low (specially in the case group), and the historical controls may be susceptible to selection bias.\u003c/p\u003e \u003cp\u003eOur study included a single case group with thyroidectomies performed by a high-volume surgeon, so our inferences and conclusions are limited to the lack of results from the use of fluorescence in low-volume surgeons. By including this additional group, we could find out if there is a real role for ICG in low-volume surgeons, since most of the studies carried out in this regard have been carried out in groups of expert surgeons and the results may not be evident.\u003c/p\u003e \u003cp\u003eFinally, this is our learning curve in the use of ICG fluorescence, so results may not show benefits until we reach an experienced and consistent use of the technique. However, we hope that this technique may have a greater impact in hospitals with trainee residents and less experienced surgeons (such as recent graduates), especially for location, tissue confirmation, and proper dissection of the parathyroid glands (by showing their arterial supply with fluorescence).\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eOur results demonstrated that the use of fluorescence with ICG dye reduces the incidence of transient and permanent hypocalcemia, however it does not reach statistical significance in comparison with the results of more experienced surgeons (high-volume thyroid surgeon). These results should be evaluated by prospective randomized studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement:\u003c/strong\u003e No competing financial interest exists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information:\u003c/strong\u003e No funding was received for this article, however we thank the Deputy Director of Health Services of Petr\u0026oacute;leos Mexicanos for providing the means to perform the surgical procedures on the patients.\u003c/p\u003e\n\u003cp\u003eInstitutional Review Board of Ethics approved the study (DCAS-SSS-HCN-ENS-140-20).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJorge Montalvo was the main surgeon in every surgical cases.Carlos J. Mata, Eduardo Jordan, Jorge Boy, Ximena Mor\u0026aacute;n assisted in the surgeries.All autores review the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhou HY, He JC, McHenry CR. Inadvertent parathyroidectomy: incidence, risk factors and ouctomes. J Surge Res. 2016;205:70\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdafe O, Antakia R, Laskar N, Uttley L, Balasubramanian SP. Systematic review and meta-analysis of predictors of post-thyroidectomy hipocalcaemia. Br J Surg. 2014;101:307\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFama F, Cicciu M, Polito F, Cascio A, Gioffre.Florio M, et al. Parathyroid autotrasplantation during thyroid surgery: a novel technique using a cell culture nutrient solution. World J Surg. 2017;41:457\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsari R, Passler C, Kaczirek K, Scheuba C, Niederle B. Hypoparathyroidism after total thyroidectomy: a prospective study. Arch Surg. 2008;143:132\u0026ndash;7. (Discussion 8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorente-Poch L, Sancho J, Munoz JL, Gallego-Otaegui L, Mar- tinez-Ruiz C, Sitges-Serra A. Failure of fragmented parathyroid gland autotransplantation to prevent permanent hypoparathyroidism after total thyroidectomy. Langenbeck\u0026rsquo;s Arch Surg. 2017;402:281\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaha AR, Jaffe BM. Parathyroid preservation during thyroid surgery. Am J Otolaryngol. 1998;19:113\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorente-Poch L, Sancho JJ, Ruiz S, Sitges-Serra A. Importance of in situ preservation of parathyroid glands during total thyroidectomy. Br J Surg. 2015;102:359\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerrera M, Grant C, van Heerden JA, Fitzpatrick LA. Parathyroid autotransplantation. Arch Surg. 1992;127:825\u0026ndash;9. (Dis- cussion 9\u0026ndash;30).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSierra M, Herrera MF, Herrero B, Jimenez F, Sepulveda J, et al. Prospective biochemical and scintigraphic evaluation of 123 autografted normal parathyroid glands in patients undergoing thyroid operations. Surgery. 1998;124:1005\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWells SA Jr, Gunnells JC, Shelburne JD, Schneider AB, Sherwood LM. Transplantation of the parathyroid glands in man: clinical indications and results. Surgery. 1975;78:34\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGioux S, Choi HS, Frangioni JV. Image-guided surgery using invisible near-infrared light: Fundamentals of clinical translation. Mol Imaging. 2010;9:237\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChand G, Agarwal S, Mishra A, et al. The impact of uniform capsular dissection technique of total thyroidectomy on postoperative complications: an experience of more than 1000 total thyroidectomies from and endocrine surgery training center in North India. Indian J Endocrinol Metab. 2018;22(3):362\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChowdury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94(2):145\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdam MA, Thomas S, Youngwirth L, et al. Is there a minimum number of thyroidectomies a surgeon should perform to optimize patient outcomes? Ann Surg. 2017;265(2):402\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoni L, David G, Mangano A, et al. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc. 2015;29(7):2046\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapavramidis TS, Anagnostis P, Chorti A, Pliakos I, Panidis S, Koutsoumparis D, Michalopoulos A. Do Near-Infrared Intra-Operative Findings Obtained Using Indocyanine Green Correlate with Post-Thyroidectomy Parathyroid Function? the Icgpredict Study. Endocr Pract. 2020;26(9):967\u0026ndash;973. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4158/EP-2020-0119\u003c/span\u003e\u003cspan address=\"10.4158/EP-2020-0119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 33471701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel N, Scott-Coombes D. Impact of surgical volume and surgical outcome assessing registers on the quality of thyroid surgery. Best Pract Res Clin Endocrinol Metab. 2019;33(4):101317. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.beem.2019.101317\u003c/span\u003e\u003cspan address=\"10.1016/j.beem.2019.101317\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Aug 31. PMID: 31526606.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarsl\u0026oslash;f T, Rolighed L, Rejnmark L. Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review. Endocrine. 2019;64:176\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaidi N, Bucak E, Yazici P, Soundararajan S, Okoh A, Yigitbas H, Dural C, Berber E. The feasibility of indocyanine green fluorescence imaging for identifiying and assessing the perfusion of parathyroid glans during total thyroidectomy. J Surg Oncol. 2016;113(7):775\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu HW, Chung JW, Yi JW, Song RY, Lee JH, Kwon H, Kim SJ, Chai YJ, Choi JY, Lee KE. Intraoperative localization of the parathyroid glands with indocyanine green and Firefly\u0026reg; technology during BABA robotic thyroidectomy. Surg Endosc J. 2017;31(7):3020\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Surgical indications for total thyroidectomy\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"400\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\"\u003e\n \u003cp\u003eTOTAL THYROIDECTOMY INDICATIONS (n=97)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.25%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.25%\"\u003e\n \u003cp\u003e# cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.5%\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.25%\"\u003e\n \u003cp\u003eindeterminate nodules\u003c/p\u003e\n \u003cp\u003e(*Bethesda III y IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.25%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.5%\"\u003e\n \u003cp\u003e(36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.25%\"\u003e\n \u003cp\u003eThyroid cancer\u003c/p\u003e\n \u003cp\u003e(Bethesda VI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.25%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.5%\"\u003e\n \u003cp\u003e(32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.25%\"\u003e\n \u003cp\u003eMultinodular goiter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.25%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.5%\"\u003e\n \u003cp\u003e(23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.25%\"\u003e\n \u003cp\u003eSuspicious of malignancy (Bethesda V)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.25%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.5%\"\u003e\n \u003cp\u003e(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.25%\"\u003e\n \u003cp\u003eNondiagnostic or unsatisfactory (Bethesda I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.25%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.5%\"\u003e\n \u003cp\u003e(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.25%\"\u003e\n \u003cp\u003eHyperparathyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.25%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.5%\"\u003e\n \u003cp\u003e(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Diagnostic categories of The Bethesda System for Reporting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThyroid Cytopathology (TBSRTC)\u003c/p\u003e\n\u003cp\u003eTable 2. Demographic, preoperative and operative features for ICG fluorescence treated patients, controls treated by high-volume thyroid surgeon and by a low-volume thyroid surgeon.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"589\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eICG fluorescence group (n=18)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLow-volume thyroid surgeon\u003c/em\u003e\u003cem\u003e, A\u003c/em\u003e\u003cem\u003e\u0026nbsp;group (n=\u003c/em\u003e\u003cem\u003e29\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHigh-volume thyroid surgeon\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eB\u0026nbsp;\u003c/em\u003e\u003cem\u003egroup (n=\u003c/em\u003e\u003cem\u003e50\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eGender\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFemale n(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e14 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e22\u0026nbsp;(76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e43 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMale n(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e4 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e7\u0026nbsp;(24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e7 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAge (years)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e54 \u0026plusmn; 13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e56 \u0026plusmn; 12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e57.5 \u0026plusmn; 14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSurgical procedure\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTotal thyroidectomy n(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e13 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e25 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e39 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTT \u0026nbsp;+ CCLND n(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e4\u0026nbsp;(22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e4 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e4\u0026nbsp;(8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTT + CCLND + LCLND n(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e7\u0026nbsp;(14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOperative time (min)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e110 \u0026plusmn; 28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e130 \u0026plusmn; 42.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e120 \u0026plusmn; 53.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBlood loss (mL)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e30 \u0026plusmn; 36.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e75 \u0026plusmn; 47.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e35 \u0026plusmn; 41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;0.001*\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHospital stay\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAutotransplantation of parathryoid tissue\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCalcium Level at 24h (mg/ml)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e8.6 (7.7-9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e8.1 (7.2-9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e8.4 (6.9-9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;1 month (mg/ml)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e9.4 (8.7-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e8.8 (6.7-9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e9.2 (8.2-9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e6 month (mg/ml)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e9.2 (8.8-9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e9.0 (6.5-11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e9.1 (7.3-10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHistopathological report\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMalignant disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e9 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e22 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e27 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.82342954159593%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBenign disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.6383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e9 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.99660441426146%\" valign=\"top\"\u003e\n \u003cp\u003e7 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.166383701188455%\" valign=\"top\"\u003e\n \u003cp\u003e23 (46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.375212224108658%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Statistically significant\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTN: thyroid nodule, TT: total thyroidectomy, CCLND: central compartment lymph node dissection, LCLND:\u0026nbsp;\u003c/em\u003e\u003cem\u003eUni-\u003c/em\u003e\u003cem\u003elateral compartment lymph node dissection\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. \u003cem\u003eTRANSIENT HYPOCALCEMIA\u003c/em\u003e using ICG-Fluorescence. Comparative results with Low- and High thyroid surgeon (A and B respectively)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"589\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.960950764006792%\"\u003e\n \u003cp\u003e3.A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.85398981324279%\" colspan=\"5\"\u003e\n \u003cp\u003eTransient Hypocalcemia\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eICG-Fluorescence versus Low-volume thyroid surgeon\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.185059422750424%\" valign=\"bottom\"\u003e\n \u003cp\u003e(n=47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9727891156462585%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.1156462585034%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.653061224489796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.217687074829932%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9727891156462585%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.1156462585034%\"\u003e\n \u003cp\u003eICG-Fluorescence cases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003e(84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.653061224489796%\"\u003e\n \u003cp\u003e(16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.217687074829932%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.9727891156462585%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.1156462585034%\"\u003e\n \u003cp\u003eControl group A (low volume\u0026nbsp;thyroid\u0026nbsp;surgeon)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003e(45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.013605442176871%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.653061224489796%\"\u003e\n \u003cp\u003e(55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.217687074829932%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep=\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"467\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e3.B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.66167023554604%\" colspan=\"5\"\u003e\n \u003cp\u003eTransient Hypocalcemia\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eICG-Fluorescence versus High-volume thyroid surgeon\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\" valign=\"bottom\"\u003e\n \u003cp\u003e(n=68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003eICG-Fluorescence cases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e(84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e(16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003eControl group B (high\u0026nbsp;volume\u0026nbsp;thyroid\u0026nbsp;surgeon)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e(56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e(44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep=\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e0.0\u003c/strong\u003e\u003cstrong\u003e39\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 4. \u003cem\u003ePERMANENT HYPOCALCEMIA\u003c/em\u003e using ICG-Fluorescence. Comparative results with Low- and High thyroid surgeon (A and B respectively)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"467\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e4.A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.66167023554604%\" colspan=\"5\"\u003e\n \u003cp\u003ePermanent\u0026nbsp;Hypocalcemia\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eICG-Fluorescence versus Low-volume thyroid surgeon\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\" valign=\"bottom\"\u003e\n \u003cp\u003e(n=47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003eICG-Fluorescence cases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e(\u0026empty;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003eControl group A (low volume\u0026nbsp;thyroid\u0026nbsp;surgeon)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e(69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e(31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep=\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"467\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e4.B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"73.66167023554604%\" colspan=\"5\"\u003e\n \u003cp\u003ePermanent\u0026nbsp;Hypocalcemia\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eICG-Fluorescence versus High-volume thyroid surgeon\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\" valign=\"bottom\"\u003e\n \u003cp\u003e(n=68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003eICG-Fluorescence cases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e(\u0026empty;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0663811563169165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.97216274089936%\"\u003e\n \u003cp\u003eControl group B (High\u0026nbsp;volume\u0026nbsp;thyroid\u0026nbsp;surgeon)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e(94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.993576017130621%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.708779443254818%\"\u003e\n \u003cp\u003e(6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.271948608137045%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep=\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e0.\u003c/strong\u003e\u003cstrong\u003e288\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"thyroidectomy, fluorescence, indocyanine green, postoperative hypocalcemia, parathyroid glands","lastPublishedDoi":"10.21203/rs.3.rs-4427077/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4427077/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Postoperative hypocalcemia is the most frequent complication of the total thyroidectomy. New techniques have recently emerged for the identification of the parathyroid glands, for example fluorescence with indocinaine green, which has been very well accepted by different groups of expert surgeons internationally. In this study we use it to assess the viability of the parathyroid glands after total thyroidectomy with the angiography image that it provides us.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis is a cohort study including patients undergoing total thyroidectomy in 2020 using ICG fluorescence and they were evaluated for transient and permanent (\u0026gt;6 months) hypocalcemia postoperatively. In addition, results were compared with historical controls including patients treated by a low-volume thyroid surgeon (group A), and by a high-volume thyroid surgeon (group B). Several variables were included (number of auto-transplanted parathyroids, postoperative serum calcium leves, and symptoms of hypocalcemia) and analyzed between groups. The main aim of the study was to determine whether the use of ICG fluorescence associateswith a lower rate of postoperative hypocalcemia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 18 patients were operated using ICG fluorescence. Of them 14 (75%) cases were females and median age were 54 ±13.5 years. 29 patients were included in group A (operated by a low-volume thyroid surgeon) and 50 patients in group B (by a high-volume thyroid surgeon). Autotransplantation was no necessary in ICG group compared with 3 and 1 in the group A and B respectively. Thyroid cancer were confirmed in 58 (59%) of cases by histopathology. Postoperative calcium levels were higher in ICG fluorescence group compared with groups A and B since day-1 to 6 months of follow-up (\u003cem\u003ep\u003c/em\u003e=NS). Statistical analysis showed a significant difference in transient hypocalcemia and permanent hypoparathyroidism rates (\u003cem\u003ep=0.011\u003c/em\u003e and \u003cem\u003ep=0.002\u003c/em\u003e respectively) when contrasted between groups. The sub-analysis showed that ICG-fluorescence did not reach adequate statistical significance compared to group of high-volume surgeon (B), both for transient and permanent hypocalcemia (p= 0.039 and p= 0.28 respectively).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: ICG fluorescence technique was associated with lower incidence of postoperative hypocalcemia specially when it is compared to low-volume thyroid surgeon.\u003c/p\u003e","manuscriptTitle":"Initial experience with ICG fluorescence during total thyroidectomy in Mexico: The postoperative hypocalcemia index decreases?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 18:45:14","doi":"10.21203/rs.3.rs-4427077/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb9e5e12-e0bd-4535-824a-506555528d58","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-24T14:11:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 18:45:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4427077","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4427077","identity":"rs-4427077","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}