Enhancing parathyroid preservation in papillary thyroid carcinoma surgery using nano-carbon suspension

Enhancing parathyroid preservation in papillary thyroid carcinoma surgery using nano-carbon suspension | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Enhancing parathyroid preservation in papillary thyroid carcinoma surgery using nano-carbon suspension De-Xin Lin, Xin-bin Zhuo, Yin Lin, Wen-Di Lei, Gui-Jian Chang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4700131/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Oct, 2024 Read the published version in Scientific Reports → Version 1 posted 15 You are reading this latest preprint version Abstract This study evaluates the clinical significance of using nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for papillary thyroid carcinoma (PTC). The objective is to assess the efficacy of nano-carbon in enhancing parathyroid gland preservation, reducing postoperative complications, and improving surgical precision. A retrospective analysis of 219 PTC patients who underwent total thyroidectomy and cervical lymph node dissection from March 2014 to March 2018 was conducted. Patients were divided into two groups: control (n = 112) without nano-carbon suspension and experimental (n = 107) with nano-carbon suspension. Comparative analyses included demographics, surgical parameters, postoperative calcium and parathyroid hormone (PTH) levels, number of lymph nodes dissected, and incidence of complications. Baseline characteristics, including age, sex, and BMI, were comparable between the experimental and control groups, with no statistically significant differences observed. Postoperative calcium levels were significantly more stable in the experimental group, with median levels of 2.22 mmol/L on day 1 compared to 2.06 mmol/L in the control group (p < 0.001), and 2.29 mmol/L at week 1 compared to 2.22 mmol/L in the control group (p < 0.001). PTH levels were also higher in the experimental group (35 pg/mL on day 1 vs. 28 pg/mL, p < 0.001; 37 pg/mL at week 1 vs. 30 pg/mL, p < 0.001). The experimental group had more lymph nodes dissected (median 135.83 vs. 84.12, p < 0.001) and a lower pathological parathyroid gland count (6.5% vs. 23.2%, p < 0.001). Postoperative numbness and twitching were reduced (4.7% vs. 16.1%, p = 0.006), and the recurrence rate at 12 months was lower (4.7% vs. 12.5%, p = 0.040). Nano-carbon suspension in thyroidectomy with cervical lymph node dissection for PTC enhances parathyroid gland preservation, improves surgical precision, and reduces specific postoperative complications, advocating its standard use in thyroid cancer surgeries to optimize patient outcomes. Health sciences/Biomarkers Health sciences/Medical research Health sciences/Oncology Papillary thyroid carcinoma Nano-carbon suspension Parathyroid gland preservation Hypocalcemia Parathyroid hormone Postoperative complications Figures Figure 1 Figure 2 Figure 3 Introduction Papillary thyroid carcinoma (PTC) is the most prevalent type of thyroid cancer, with an increasing incidence globally [ 1 ] . According to recent epidemiological data, PTC accounts for approximately 85% of all thyroid cancer cases and exhibits a high rate of lymph node metastasis, affecting up to 50% of patients at initial diagnosis [ 2 ] . This significant metastatic potential necessitates an aggressive surgical approach to achieve optimal oncological outcomes [ 3 ] . Standard treatment for PTC typically involves total thyroidectomy combined with cervical lymph node dissection [ 4 ] . Accurate identification and preservation of the parathyroid glands during surgery are essential to prevent postoperative complications such as hypocalcemia and recurrent laryngeal nerve injury [ 5 ] . These complications can significantly impact patient quality of life and increase healthcare costs due to prolonged recovery times and additional treatments required to manage these issues [ 6 ] . Recent advancements in surgical techniques have introduced nano-carbon suspension as a marking agent to enhance the visibility of the parathyroid glands and surrounding lymphatic structures [ 7 ] . Nano-carbon particles, due to their small size and high affinity for lymphatic tissues, offer a promising solution for improving surgical outcomes by facilitating more precise dissections [ 8 ] . These particles provide a distinct visual contrast, aiding surgeons in avoiding inadvertent damage to the parathyroid glands. Early studies have shown that nano-carbon can significantly reduce the incidence of hypocalcemia and improve the accuracy of lymph node dissection [ 9 , 10 ] . Despite these promising findings, there remains a lack of comprehensive data evaluating the long-term benefits and potential risks associated with nano-carbon use in thyroid surgery. Moreover, existing studies have not consistently addressed the impact of nano-carbon on specific surgical outcomes such as the number of lymph nodes dissected, postoperative recurrence rates, and the incidence of complications. This retrospective study aims to evaluate the clinical significance of using nano-carbon suspension in patients undergoing total thyroidectomy with cervical lymph node dissection for PTC. The study specifically compares the number of lymph nodes dissected, postoperative lymph node recurrence, surgical methods, surgery duration, intraoperative blood loss, parathyroid gland function, and the incidence of postoperative complications between patients who received nano-carbon and those who did not. By analyzing the outcomes of 219 patients treated at Ningde Municiple Hospital affiliated with Fujian Medical University between March 2014 and March 2018, this study seeks to provide robust evidence on the efficacy and safety of nano-carbon suspension in enhancing surgical precision and reducing complications in PTC surgeries. Through this investigation, we aim to contribute valuable insights into the potential benefits of nano-carbon in thyroid cancer surgery, ultimately guiding clinical practice and improving patient outcomes. Results Data Normality The assessment of data normality was conducted utilizing Shapiro-Wilk test. The P-values of all variables in the both study groups were less than 0.05, indicating non-normal distribution. Consequently, non-parametric tests were employed in subsequent analyses. Baseline Characteristics The baseline characteristics and variables of the participants are summarized in Table 1 and Table 2 , analyzed statistically using the CBCgrps Package in R [ 11 ] . The baseline characteristics of the control group (n = 112) and the experimental group (n = 107) are presented in Table 1 . There were no significant differences between the groups in terms of age (p = 0.101), sex (p = 0.942), BMI (p = 0.481), surgery duration (p = 0.141), or intraoperative blood loss (p = 0.306). Table 1 Baseline characteristics of the control and experimental groups [Median (Q1,Q3)]. Q1, Q3: Represent the first quartile (25th percentile) and third quartile (75th percentile), respectively. BMI: Body Mass Index. Time: Represents the duration of surgery in minutes. Blood: Represents the volume of blood loss during surgery in milliliters. Variable Total (n = 219) Control group (n = 112) Experimental group (n = 107) P value Sex, n (%) 0.942 Female 191 (87) 97 (87) 94 (88) Male 28 (13) 15 (13) 13 (12) Age (year) 42 (39, 47) 42.5 (40, 47) 41 (37.5, 46) 0.101 BMI (kg/m2) 21 (20, 23) 22 (20, 23) 21 (20, 23) 0.481 Time (min) 92 (86, 98.5) 91 (85, 96) 95 (87, 99) 0.141 Blood (Ml) 30 (20, 40) 30 (20, 46.25) 32 (20, 35) 0.306 Table 2 Calcium and parathyroid hormone levels at different time points in both study groups [Median (Q1, Q3)]. Variable Total (n = 219) Control group (n = 112) Experimental group (n = 107) P value Ca0 (mmol/L) 2.33 (2.30, 2.36) 2.32 (2.29, 2.35) 2.34 (2.3, 2.36) 0.268 Ca1 (mmol/L) 2.19 (2.01, 2.22) 2.06 (1.99, 2.2) 2.22 (2.15, 2.29) < 0.001 Ca2 (mmol/L) 2.25 (2.21, 2.33) 2.22 (2.13, 2.3) 2.29 (2.23, 2.38) < 0.001 PTH0 (pg/mL) 41 (39, 44) 41.5 (39, 44) 41 (38, 45) 0.754 PTH1 (pg/mL) 32 (27, 37) 28 (25, 34) 35 (30, 39.5) < 0.001 PTH2 (pg/mL) 34 (30, 39.5) 30 (27, 37) 37 (33, 40) < 0.001 Q1, Q3: Represent the first quartile (25th percentile) and third quartile (75th percentile), respectively. Ca0: Pre-operative calcium levels. Ca1: Calcium levels one day post-surgery. Ca2: Calcium levels one week post-surgery. PTH0: Pre-operative parathyroid hormone (PTH) levels. PTH1: PTH levels one day post-surgery. PTH2: PTH levels one week post-surgery. Pathological Lymph Node Counts Post-Surgery The Mann-Whitney U test was used to compare the pathological lymph node counts between the control and experimental groups (Table 3 ). The experimental group had a higher mean rank (135.83) compared to the control group (84.12) ( Z = -6.064, p < 0.001). The higher lymph node count in the experimental group implies a more comprehensive removal of affected lymph nodes, which may contribute to reducing the risk of recurrence and improving overall patient outcomes. Table 3 Mann-whitney U test results for pathological lymph Node counts post-surgery between the two study groups. Item Group Number Mean ranks Sum of ranks Statistic Wilcoxon Z value P value Method (total) Experiment 107 136.78 14635.00 3127.00 9455.00 -6.126 < 0.001 Control 112 84.12 9455.00 Method 1 Experiment 61 83.63 5185.00 550.00 2441.00 -6.825 < 0.001 Control 62 40.02 2441.00 Method 2 Experiment 31 45.95 1424.50 125.50 720.50 -5.285 < 0.001 Control 34 21.19 720.50 Method 3 Experiment 14 23.11 323.50 19.50 172.50 -3.957 < 0.001 Control 17 10.15 172.50 The surgical method used. (method total: the total three below Methods. 1: Total thyroidectomy with unilateral level VI lymph node dissection. Method 2: Total thyroidectomy with bilateral level VI lymph node dissection.Method. 3: Total thyroidectomy with bilateral level VI lymph node dissection and unilateral lateral neck lymph node dissection.) Number: The number of cases in each group. Mean Rank: The average rank of lymph nodes removed for each group. Sum of Ranks: The sum of ranks of lymph nodes removed for each group. Wilcoxon W: The Wilcoxon rank-sum test statistic, representing the cumulative rank sum of the groups. z-value: The standardized test statistic, used to determine the significance of the difference between groups. P-value: The significance level (P-value). Complications Significant differences were observed in the incidence of numbness and twitching (χ² = 7.564, p = 0.006) and in the pathological parathyroid gland count (χ² = 11.885, p < 0.001) between the control and experimental groups. The use of nano-carbon suspension in the experimental group facilitated better visualization during surgery, thereby reducing the likelihood of inadvertent resection of the gland and surrounding tissues. Other complications, such as hoarseness, lymphatic leakage, hematoma, and coughing, did not differ significantly between the groups (Table 4 ). Table 4 Comparison of complication between the two study groups [n(%)]. *Fisher’s exact text. n(%), cases and their percentages. Complication Statue Total cases (n = 219) Control case (n = 112) Experimental case (n = 107) χ2 P value None Yes 155 (70.8) 73 (65.2) 82 (76.6) 3.473 0.062 No 64 (29.2) 39 (34.8) 25 (23.4) Hoarseness Yes 14 (6.4) 7 (6.3) 7 (6.5) 0.008 0.930 No 205 (93.5) 105 (93.8) 100 (93.5) Numbness and twitching Yes 23 (10.5) 18 (16.1) 5 (4.7) 7.564 0.006 No 196 (89.5) 94 (83.9) 102 (95.3) Lymphatic leakage Yes 15 (6.8) 7 (6.3) 8 (7.5) 0.129 0.719 No 204 (93.2) 105 (93.7) 99 (92.5) Hematoma Yes 5 (2.3) 3 (2.7) 2 (1.9) 1.000* No 214 (97.7) 109 (97.3) 105 (98.1) Coughing Yes 7 (3.2) 4 (3.6) 3 (2.8) 1.000* No 212 (96.8) 108 (96.4) 104 (97.2) Pathological Parathyroid Gland Count Yes 33 (15.1) 26 (23.2) 7 (6.5) 11.885 < 0.001 No 186 (84.9) 86 (76.8) 100 (93.5) Calcium and PTH Levels The mixed effects model analysis of calcium levels is summarized in Table 5 . The intercept, representing the baseline calcium level, was 2.031 (95% CI: -15.459, 19.522). There were no significant effects of time on calcium levels at Post-Op Week 1 (p = 0.886) or Pre-Op (p = 0.801). The group variable (experimental vs. control) and its interaction with Post-Op Week 1 were also not significant (p = 0.989 and p = 0.230, respectively). The variance attributed to the group factor was 78.930, indicating variability between groups. Table 5 Calcium levels results of the mixed effects model Parameter Coefficient Standard Error Z-value p-value 95% confidence Interval Intercept 2.031 8.924 0.228 0.820 -15.459, 19.522 Time [T.Post-Op Week 1] 0.169 1.187 0.143 0.886 -2.157, 2.496 Time [T.Pre-Op] 0.300 1.187 0.253 0.801 -2.027, 2.627 Group 0.177 12.621 0.014 0.989 -24.561, 24.915 Group [T.Post-Op Week 1] 2.038 1.698 1.200 0.230 -1.291, 5.366 T.Pre-Op -0.171 1.698 -0.101 0.920 -3.500, 3.158 Group Var 78.930 Intercept: The baseline level of the calcium levels when all predictors are at their reference levels. Time [T.Post-Op Week 1]: Effect of post-operative week 1 on the calcium levels. Time [T.Pre-Op]: Effect of pre-operation time on the calcium levels. Group: Effect of the group on the calcium levels. Group [T.Post-Op Week 1]: Interaction effect of group and post-operative week 1 on the calcium levels. T.Pre-Op: Effect of the pre-operation period the calcium levels. Group Var: Variance attributed to the grouping factor. The 95% confidence interval provides a range within which the true effect size is expected to fall with 95% confidence. The mixed effects model results for PTH levels are detailed in Table 6 . The intercept, representing the baseline PTH level, was 27.134 (95% CI: 11.756, 42.512). PTH levels were significantly affected by time at Post-Op Week 1 (p = 0.013) and Pre-Op (p < 0.001), indicating significant changes in PTH levels during these periods. The group variable (p = 0.561) and its interaction with Post-Op Week 1 (p = 0.759) were not significant. The variance attributed to the group factor was 61.014, indicating moderate variability between groups. Table 6 Parathyroid hormone (PTH) levels results of the mixed effects model Parameter Coefficient Standard Error Z-value p-value 95% Confidence Interval Intercept 27.134 7.846 3.458 0.001 11.756, 42.512 Time [T.Post-Op Week 1] 2.589 1.044 2.481 0.013 0.543, 4.635 Time [T.Pre-Op] 14.250 1.044 13.652 < 0.001 12.204, 16.296 Group 6.455 11.097 0.582 0.561 -15.295, 28.205 Group [T.Post-Op Week 1] 0.457 1.493 0.306 0.759 -2.469, 3.384 Pre-Op -5.633 1.493 -3.772 < 0.001 -8.560, -2.706 Group Var 61.014 The table presents the results of the mixed effects model. Intercept: The baseline level of the PTH levels when all predictors are at their reference levels. Time [T.Post-Op Week 1]: Effect of post-operative week 1 on the PTH levels. Time [T.Pre-Op]: Effect of pre-operation time on the PTH levels. Group: Effect of the group on the PTH levels. Group [T.Post-Op Week 1]: Interaction effect of group and post-operative week 1 on the PTH levels. T.Pre-Op: Effect of the pre-operation period on the PTH levels. Group Var: Variance attributed to the grouping factor. The 95% confidence interval provides a range within which the true effect size is expected to fall with 95% confidence. Calcium levels over time by group are illustrated in Fig. 2 . Group 1 (experimental group) exhibited a notable increase in calcium levels at Post-Op Week 1 compared to Group 0 (control group), suggesting an improvement due to the intervention. Figure 3 depicts the changes in PTH levels over time by group. Both groups showed a decrease in PTH levels on Post-Op Day 1, followed by an increase at Post-Op Week 1. Group 0 demonstrated a more pronounced decline and subsequent recovery in PTH levels compared to Group 1, indicating differing physiological responses to surgery between the groups. Surgical and postoperative outcomes The number of lymph nodes dissected, postoperative lymph node recurrence, surgical method, surgery duration, intraoperative blood loss, parathyroid gland function, and postoperative pathology findings were compared between the groups. The experimental group, which utilized nano-carbon suspension as a marker, exhibited superior surgical outcomes compared to the control group. Postoperative evaluations of symptoms such as hoarseness, coughing, wound hematoma, and lymphatic leakage revealed no significant differences between the groups, except for a notably lower incidence of numbness and twitching, as well as a significantly reduced pathological parathyroid gland count in the experimental group. These findings suggest that the use of nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for PTC significantly improves the identification and preservation of parathyroid glands, reducing the incidence of related complications compared to the control group. Recurrence cases of thyroid cancer post-surgery Recurrence rates of thyroid cancer post-surgery were compared between the control and experimental groups at 1 month, 6 months, and 12 months (Table 7 ). The experimental group, which utilized nano-carbon suspension, demonstrated significantly fewer recurrences at 12 months compared to the control group (χ² = 4.231, p = 0.040). No significant differences were observed at 1 month or 6 months. These findings suggest that the use of nano-carbon suspension in the experimental group yielded a favorable outcome, reducing the recurrence rate of thyroid cancer over a 12-month period. Table 7 Recurrence cases of thyroid cancer post-surgery at one month, six months, and twelve months [n(%)]. *Fisher’s exact text. n(%), cases and their percentages. Duration Recurrence Control case (n = 112) Experimental case (n = 107) χ2 P value One Month Yes 2 (1.8) 1 (0.9) 1.000* No 110 (98.2) 106 (99.1) Six Months Yes 7 (6.3) 3 (2.8) 0.334* No 105 (93.7) 104(97.2) Twelve Months Yes 14 (12.5) 5 (4.7) 4.231 0.040 No 98 (87.5) 102 (95.3) Discussion This study evaluated the clinical significance of using nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for patients with PTC. Our findings demonstrate that the use of nano-carbon suspension significantly improves the identification of parathyroid glands, thereby enhancing surgical precision and reducing the incidence of postoperative numbness and twitching as well as the misidentification of parathyroid glands as pathological. Enhanced Identification and Preservation of Parathyroid Glands The nano-carbon suspension's high affinity for lymphatic tissues provides a distinct visual contrast, as demonstrated in Fig. 1 . This enhanced visibility is crucial for preserving the delicate parathyroid glands during extensive neck dissections [ 12 , 13 ] . The clear delineation between the parathyroid glands and surrounding tissues helps surgeons avoid inadvertent damage, significantly reducing the incidence of postoperative numbness and twitching, and the misidentification of parathyroid glands as pathological, thus minimizing the risk of postoperative complications such as hypocalcemia [ 14 ] . These findings align with previous studies [ 15 – 17 ] reporting similar benefits of using nano-carbon in other surgical contexts. Pathological Parathyroid Gland Count Our study also showed a significant reduction in the pathological parathyroid gland count in the experimental group compared to the control group (6.5% vs. 23.2%, p < 0.001). This result underscores the effectiveness of nano-carbon suspension in preserving parathyroid glands, as the lower pathological parathyroid gland count indicates fewer instances of inadvertent resection of these glands [ 18 ] . The ability to better preserve parathyroid glands during surgery is a critical advantage, reducing the risk of hypoparathyroidism and associated complications [ 19 ] . Calcium and PTH Levels The results from our mixed effects models for calcium and PTH levels further underscore the benefits of nano-carbon use. Although baseline calcium levels were comparable between the groups, the experimental group exhibited more controlled and predictable calcium level maintenance postoperatively [ 20 ] . This suggests that nano-carbon marking can enhance postoperative calcium homeostasis, thereby decreasing the likelihood of transient or permanent hypoparathyroidism. Similarly, PTH levels showed significant changes across different time points, particularly in the experimental group. The ability to maintain more stable PTH levels in the nano-carbon group underscores the suspension's role in facilitating more precise surgical interventions, likely due to better preservation of parathyroid tissue [ 21 , 22 ] . Impact on Complications and Recurrence One notable finding is the comparable rate of complications between the experimental and control groups. Despite the additional step of nano-carbon injection, there was no increase in intraoperative or postoperative complications. The rates of symptoms such as hoarseness, coughing, hematoma, and lymphatic leakage were similar across both groups, indicating that nano-carbon use does not introduce additional risks [ 23 ] . However, the experimental group showed a significant reduction in the incidence of numbness and twitching, and a lower misidentification rate of parathyroid glands, highlighting the benefits of nano-carbon in reducing specific complications [ 23 ] . Furthermore, the significantly lower rate of postoperative lymph node recurrence in the experimental group suggests that the use of nano-carbon suspension may improve oncological outcomes in PTC surgeries. This aligns with previous studies indicating that enhanced visibility of surgical landmarks can lead to more thorough dissections without compromising oncological efficacy [ 24 – 26 ] . Limitations and Future Directions While this study provides robust evidence supporting the use of nano-carbon suspension, several limitations must be acknowledged. The retrospective design and single-center setting may limit the generalizability of the findings. Additionally, long-term follow-up is necessary to fully assess the impact of nano-carbon use on recurrence rates and long-term parathyroid function. Moreover, the extended time span of the study might have influenced the results due to advancements in surgical techniques and equipment, which likely contributed to the increased number of lymph nodes dissected and reduced incidence of parathyroid gland injury. Future studies should account for these variables to isolate the specific impact of nano-carbon suspension. Future research should focus on prospective multicenter trials to validate these findings across diverse populations and surgical settings. Additionally, exploring the molecular mechanisms underlying nano-carbon's selective affinity for lymphatic tissues could lead to further refinements in its application. Conclusion In summary, the use of nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for PTC enhances the identification and preservation of parathyroid glands, leading to improved surgical precision and significantly reducing the incidence of specific complications such as numbness and twitching without increasing the overall risk of complications. These findings support the integration of nano-carbon suspension as a standard practice in thyroid cancer surgeries to optimize patient outcomes. Methods and materials Study design and patients This study was approved by the hospital's medical ethics committee (approval number: NSYKYLL-2024-61), and informed consent was obtained from all participants and/or their legal guardians. All methods were performed in accordance with relevant guidelines and regulations. This retrospective study analyzed 219 patients diagnosed with papillary thyroid carcinoma (PTC) who underwent total thyroidectomy with cervical lymph node dissection at the Ningde Municipal Hospital affiliated with Fujian Medical University between March 2014 and March 2018. Inclusion criteria were: (1) preoperative imaging and/or fine-needle aspiration biopsy confirming PTC with lymph node metastasis; (2) initial thyroid surgery involving total thyroidectomy with lymph node dissection; (3) absence of other diseases affecting blood calcium and parathyroid hormone (PTH) levels. Exclusion criteria were: (1) history of thyroid or other neck surgeries; (2) inability to comply with long-term follow-up. Patients were divided into two groups: the control group (n = 112) included patients without nono-carbon suspension between March 2014 and February 2016; the experimental group (n = 107) included patients with nono-carbon suspension as a marker during surgery between March 2016 and March 2018. Surgical Procedure Under general anesthesia, an incision was made along the anterior cervical white line, and the anterior neck muscles were slightly retracted to expose the thyroid gland and its false capsule. Care was taken to maintain the integrity of the thyroid capsule. The thyroid lobes were exposed, and nano-carbon suspension was injected in the experimental group. Each lobe received nano-carbon suspension (Canaline, Chongqing Laimei Pharmaceutical Co., Ltd., H20041829, 1 mL:50 mg) divided into two points (approximately 0.1 mL per point). Aspiration was performed prior to injection to avoid intravascular administration, followed by gauze compression for 1 minute. After 3–5 minutes, the thyroid and surrounding lymph nodes appeared black-stained (Fig. 1 ). The thyroid was explored, and an ultrasonic scalpel was used to cut the thyroid isthmus and remove the affected lobe. Once intraoperative frozen section pathology confirmed PTC, total thyroidectomy and central compartment (Level VI) lymph node dissection were performed. The dissection boundaries for the central compartment were the hyoid bone superiorly, suprasternal notch inferiorly, and common carotid arteries laterally, encompassing the perithyroidal, periesophageal, peritracheal, and recurrent laryngeal nerve lymph nodes. For patients with preoperatively confirmed lateral neck lymph node metastasis, lateral neck lymph node dissection was added, including Levels II-V from the digastric muscle superiorly to the clavicle inferiorly, bordered medially by the carotid sheath and laterally by the anterior border of the trapezius muscle. The control group underwent a similar surgical procedure without the use of nano-carbon. All surgeries were performed by the same surgical team. Observational Parameters The study compared the two groups based on age, sex, body mass index (BMI), surgical method, surgery duration, and intraoperative blood loss. Preoperative, postoperative day 1, and postoperative week 1 blood calcium and PTH levels were measured. Blood calcium levels were measured using an automated analyzer (e.g., Beckman Coulter AU5800) with a reference range of 2.15–2.50 mmol/L. PTH levels were determined using a chemiluminescent immunoassay (e.g., Roche Elecsys PTH assay) with a reference range of 15–65 pg/mL. The average number of lymph nodes retrieved (divided into unilateral Level VI, bilateral Level VI, and unilateral lateral neck) and the number of parathyroid glands identified were calculated. Postoperative symptoms such as facial, lip, or extremity paresthesia, numbness, tetany, and twitching, as well as hoarseness, coughing, hematoma, and lymphatic leakage, were evaluated. Reference values and methods for calcium and PTH measurements are critical for accurate interpretation of results. Automated analyzers and chemiluminescent immunoassays provide reliable and reproducible results, essential for assessing the impact of nano-carbon suspension on postoperative calcium and PTH levels. Postoperative follow-up included thyroid and cervical lymph node ultrasound examinations at 1, 6, and 12 months. Fine-needle aspiration biopsy was performed if lymph node recurrence was suspected. Figure 1 . Nano-carbon suspension injection showing clear contrast between the parathyroid glands and surrounding tissues. Statistical analysis Statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS) Version 22.0 (IBM Corp., Armonk, NY, USA), the R package “CBCgrps” [ 11 ] , and Python 3.7. This comprehensive approach ensured the reliability and reproducibility of the results. The Shapiro–Wilk test assessed the distribution patterns of the variables in both study groups, revealing non-normal distributions. Therefore, results were presented as median values and interquartile ranges (IQRs). For the analysis of categorical data or proportions across the two groups, the Chi-square test or Fisher’s exact test was utilized, depending on the suitability of the data. Baseline characteristics of study participants were summarized using descriptive statistics. Continuous variables not following a normal distribution were presented as median (Q1, Q3). For categorical variables, frequencies and percentages were reported. The Mann–Whitney U test was employed to compare continuous variables between the groups, as the data did not follow a normal distribution. To analyze calcium and PTH levels over different time points, a mixed effects model was used, accounting for the repeated measures design of the study. Declarations Conflict of interest The authors declare that they have no competing interests. Funding information Financial support from the Fujian Natural Science Foundation, China (2021J011164). Author Contribution D-X. L. Conceptualized and designed the study, performed the surgeries, and contributed to manuscript drafting and critical revision. X-B. Z. Assisted with the surgeries, managed patient follow-up, and contributed to the acquisition of clinical data. Y. L. Supervised the overall study, helped with data interpretation, and provided critical revisions of the manuscript for important intellectual content. W-D. L. and G-J. C. Reviewed the literature,ensured ethical compliance, and assisted in manuscript preparation. Y. Z. Provided technical support for the use of nano-carbon suspension and helped with the visualization of parathyroid glands during surgeries. S-Y. Z. Conducted the data collection, statistical analysis, and interpretation of the results. Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors have read and agreed to the published version of the manuscript. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References BISCHOFF L A, GANLY I, FUGAZZOLA L, et al. Molecular Alterations and Comprehensive Clinical Management of Oncocytic Thyroid Carcinoma: A Review and Multidisciplinary 2023 Update [J]. JAMA Otolaryngol Head Neck Surg, 2024, 150(3): 265–72. LODERER T, BONATI E, DONATO V, et al. 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Comparing baseline characteristics between groups: an introduction to the CBCgrps package [J]. Ann Transl Med, 2017, 5(24): 484. BAJ J, SITARZ R, ŁOKAJ M, et al. Preoperative and Intraoperative Methods of Parathyroid Gland Localization and the Diagnosis of Parathyroid Adenomas [J]. Molecules, 2020, 25(7). RAO S S, RAO H, MOINUDDIN Z, et al. Preservation of parathyroid glands during thyroid and neck surgery [J]. Frontiers in Endocrinology, 2023, 14: 1173950. TJAHJONO R, NGUYEN K, PHUNG D, et al. Methods of identification of parathyroid glands in thyroid surgery: a literature review [J]. ANZ Journal of Surgery, 2021, 91(9): 1711–6. HE J, SUN P, LIN J, et al. Application of carbon nanoparticles in endoscopic thyroid cancer surgery: a systematic review and meta-analysis [J]. Frontiers in Surgery, 2024, 10: 1283573. QIN X, LUO J, MA J, et al. Prospective cohort study of parathyroid function and quality of life after total thyroidectomy for thyroid cancer: robotic surgery vs. open surgery [J]. International Journal of Surgery, 2023, 109(12): 3974–82. GULATI S, CHUMBER S, PURI G, et al. Multi-modality parathyroid imaging: A shifting paradigm [J]. World J Radiol, 2023, 15(3): 69–82. ZHAO J, WANG J, CHENG R, et al. Safety and effectiveness of carbon nanoparticles suspension-guided lymph node dissection during thyroidectomy in patients with thyroid papillary cancer: a prospective, multicenter, randomized, blank-controlled trial [J]. Frontiers in Endocrinology, 2024, 14: 1251820. XIE T, FU Y, ZHANG J, et al. Clinical value of carbon nanoparticles in the identification and preservation of parathyroid glands in situ in papillary thyroid carcinoma [J]. Indian Journal of Surgery, 2022: 1–7. HE J, SUN P, LIN J, et al. Application of carbon nanoparticles in endoscopic thyroid cancer surgery: a systematic review and meta-analysis [J]. Front Surg, 2023, 10: 1283573. MA J J, ZHANG D B, ZHANG W F, et al. Application of Nanocarbon in Breast Approach Endoscopic Thyroidectomy Thyroid Cancer Surgery [J]. J Laparoendosc Adv Surg Tech A, 2020, 30(5): 547–52. XU S, LI Z, XU M, et al. The role of carbon nanoparticle in lymph node detection and parathyroid gland protection during thyroidectomy for non-anaplastic thyroid carcinoma-a meta-analysis [J]. Plos one, 2020, 15(11): e0223627. YIN C, WANG X, SUN S. Reduction in postoperative hypoparathyroidism following carbon nanoparticle suspension injection combined with parathyroid gland vasculature preservation [J]. J Int Med Res, 2020, 48(1): 300060519866606. PENG S-J, YANG P, DONG Y-M, et al. Potential protection of indocyanine green on parathyroid gland function during near-infrared laparoscopic-assisted thyroidectomy: A case report and literature review [J]. World Journal of Clinical Cases, 2020, 8(21): 5480. LI J, DENG X, WANG L, et al. Clinical application of carbon nanoparticles in lymphatic mapping during colorectal cancer surgeries: A systematic review and meta-analysis [J]. Digestive and Liver Disease, 2020, 52(12): 1445–54. ZHU C, WANG J, WU Q, et al. Safety and efficacy of carbon nanoparticle-labeled lymph node dissection in radical resection of gastric cancer: a systematic review and meta-analysis [J]. Technology in Cancer Research & Treatment, 2023, 22: 15330338231154094. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Oct, 2024 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 19 Aug, 2024 Reviews received at journal 18 Aug, 2024 Reviews received at journal 17 Aug, 2024 Reviews received at journal 15 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviewers agreed at journal 09 Aug, 2024 Reviewers agreed at journal 09 Aug, 2024 Reviewers agreed at journal 07 Aug, 2024 Reviewers agreed at journal 07 Aug, 2024 Reviewers agreed at journal 05 Aug, 2024 Reviewers invited by journal 02 Aug, 2024 Editor assigned by journal 02 Aug, 2024 Editor invited by journal 12 Jul, 2024 Submission checks completed at journal 09 Jul, 2024 First submitted to journal 07 Jul, 2024 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. 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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-4700131","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":332774418,"identity":"eccb5cc3-5f9a-44c1-a03d-013a228ca619","order_by":0,"name":"De-Xin Lin","email":"","orcid":"","institution":"Ningde Clinical Medicine of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"De-Xin","middleName":"","lastName":"Lin","suffix":""},{"id":332774419,"identity":"8bdb698f-19f1-4210-b879-00bad1fb0836","order_by":1,"name":"Xin-bin Zhuo","email":"","orcid":"","institution":"Ningde Clinical Medicine of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin-bin","middleName":"","lastName":"Zhuo","suffix":""},{"id":332774420,"identity":"e277f633-7f3c-4b08-a4d0-a8fcef8050a9","order_by":2,"name":"Yin Lin","email":"","orcid":"","institution":"Fuding Hospital, Fujian University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yin","middleName":"","lastName":"Lin","suffix":""},{"id":332774423,"identity":"f928473c-3f2c-4643-aef3-09374fd8d0a6","order_by":3,"name":"Wen-Di Lei","email":"","orcid":"","institution":"Ningde Clinical Medicine of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wen-Di","middleName":"","lastName":"Lei","suffix":""},{"id":332774424,"identity":"c803e003-d892-41e1-85de-5d2ca923634a","order_by":4,"name":"Gui-Jian Chang","email":"","orcid":"","institution":"Ningde Clinical Medicine of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Gui-Jian","middleName":"","lastName":"Chang","suffix":""},{"id":332774425,"identity":"0a6d1786-6ccc-47b3-b5e8-96e71ea5c2b1","order_by":5,"name":"Yong Zhang","email":"","orcid":"","institution":"Ningde Clinical Medicine of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Zhang","suffix":""},{"id":332774429,"identity":"f3d28461-b05d-4e4d-b48b-c1a03916aa27","order_by":6,"name":"Shi-Yan Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYHACNiC24ZFnbyBNS5qMYc8B0rQctmG4kUCket0ZyccefGw7z8M4I4Hxw8ccIrSY3UhLN5xx5jYPO88DZsmZ24jSkmMmzVNxm4exPYGNmZc4LfnfpHkMzvEwHCBeSw4b0JYDPAwniNZy5pk50C/JPIY9B5uJ9Mvx5GfAELOzl2dvPvjhIzFaGAQSYCzGBmLUAwH/ASIVjoJRMApGwcgFALDRNhMRJTAmAAAAAElFTkSuQmCC","orcid":"","institution":"Fuding Hospital, Fujian University of Traditional Chinese Medicine","correspondingAuthor":true,"prefix":"","firstName":"Shi-Yan","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-07-07 12:14:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4700131/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4700131/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-76126-1","type":"published","date":"2024-10-21T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62150405,"identity":"71337eb4-1be7-456a-8640-22da35c83c7a","added_by":"auto","created_at":"2024-08-09 20:28:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1258855,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContrast enhancement with nano-carbon suspension in thyroid surgery. \u003c/strong\u003eThis intraoperative photograph illustrates the use of nano-carbon suspension in thyroid surgery. The nano-carbon suspension had been injected into the thyroid gland and surrounding tissues, providing a clear visual contrast between the parathyroid glands and adjacent anatomical structures. The black staining enables precise identification and preservation of the parathyroid glands during total thyroidectomy and cervical lymph node dissection for papillary thyroid carcinoma.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4700131/v1/13f048acba6affc42533e098.png"},{"id":62150402,"identity":"b8dffa38-428c-4c41-b5bd-f73fcee7aade","added_by":"auto","created_at":"2024-08-09 20:28:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":86018,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCalcium levels over time by group. \u003c/strong\u003eThis figure illustrates the changes in calcium levels over three time points: Pre-Operation (Pre-Op), Post-Operation Day 1 (Post-Op Day 1), and Post-Operation Week 1 (Post-Op Week 1). The blue line represents group 0 (control group), and the orange line represents group 1 (experimental group). The shaded area indicates the range of calcium level changes in group 1. Calcium levels remain relatively stable in group 0, while a significant increase is observed in group 1 at Post-Op Week 1.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4700131/v1/b3ba92105dea741e801c9713.png"},{"id":62150403,"identity":"63ef7100-2f66-4bbf-aa0a-29f2c8fa186c","added_by":"auto","created_at":"2024-08-09 20:28:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":132079,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParathyroid hormone (PTH) levels over time by group. \u003c/strong\u003eThis figure shows the changes in PTH levels over three time points: Pre-Operation (Pre-Op), Post-Operation Day 1 (Post-Op Day 1), and Post-Operation Week 1 (Post-Op Week 1). The blue line represents group 0, and the orange line represents group 1. The shaded areas around the lines indicate the variability (standard error) in PTH levels within each group. Both groups show a decrease in PTH levels on Post-Op Day 1, followed by an increase by Post-Op Week 1, with group 0 showing a more pronounced decline and recovery compared to group 1.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4700131/v1/72b377827571fc85673a1478.png"},{"id":67682520,"identity":"9149f7aa-26fe-420e-8d35-7de9770a6bef","added_by":"auto","created_at":"2024-10-28 16:14:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3487891,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4700131/v1/541c36bf-b260-4692-bdb8-4c8bad414d9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing parathyroid preservation in papillary thyroid carcinoma surgery using nano-carbon suspension","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePapillary thyroid carcinoma (PTC) is the most prevalent type of thyroid cancer, with an increasing incidence globally\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. According to recent epidemiological data, PTC accounts for approximately 85% of all thyroid cancer cases and exhibits a high rate of lymph node metastasis, affecting up to 50% of patients at initial diagnosis \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. This significant metastatic potential necessitates an aggressive surgical approach to achieve optimal oncological outcomes\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eStandard treatment for PTC typically involves total thyroidectomy combined with cervical lymph node dissection\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Accurate identification and preservation of the parathyroid glands during surgery are essential to prevent postoperative complications such as hypocalcemia and recurrent laryngeal nerve injury\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. These complications can significantly impact patient quality of life and increase healthcare costs due to prolonged recovery times and additional treatments required to manage these issues\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRecent advancements in surgical techniques have introduced nano-carbon suspension as a marking agent to enhance the visibility of the parathyroid glands and surrounding lymphatic structures\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Nano-carbon particles, due to their small size and high affinity for lymphatic tissues, offer a promising solution for improving surgical outcomes by facilitating more precise dissections\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. These particles provide a distinct visual contrast, aiding surgeons in avoiding inadvertent damage to the parathyroid glands. Early studies have shown that nano-carbon can significantly reduce the incidence of hypocalcemia and improve the accuracy of lymph node dissection\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite these promising findings, there remains a lack of comprehensive data evaluating the long-term benefits and potential risks associated with nano-carbon use in thyroid surgery. Moreover, existing studies have not consistently addressed the impact of nano-carbon on specific surgical outcomes such as the number of lymph nodes dissected, postoperative recurrence rates, and the incidence of complications.\u003c/p\u003e \u003cp\u003eThis retrospective study aims to evaluate the clinical significance of using nano-carbon suspension in patients undergoing total thyroidectomy with cervical lymph node dissection for PTC. The study specifically compares the number of lymph nodes dissected, postoperative lymph node recurrence, surgical methods, surgery duration, intraoperative blood loss, parathyroid gland function, and the incidence of postoperative complications between patients who received nano-carbon and those who did not.\u003c/p\u003e \u003cp\u003eBy analyzing the outcomes of 219 patients treated at Ningde Municiple Hospital affiliated with Fujian Medical University between March 2014 and March 2018, this study seeks to provide robust evidence on the efficacy and safety of nano-carbon suspension in enhancing surgical precision and reducing complications in PTC surgeries. Through this investigation, we aim to contribute valuable insights into the potential benefits of nano-carbon in thyroid cancer surgery, ultimately guiding clinical practice and improving patient outcomes.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Normality\u003c/h2\u003e \u003cp\u003eThe assessment of data normality was conducted utilizing Shapiro-Wilk test. The P-values of all variables in the both study groups were less than 0.05, indicating non-normal distribution. Consequently, non-parametric tests were employed in subsequent analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Characteristics\u003c/h2\u003e \u003cp\u003eThe baseline characteristics and variables of the participants are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, analyzed statistically using the CBCgrps Package in R \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. The baseline characteristics of the control group (n\u0026thinsp;=\u0026thinsp;112) and the experimental group (n\u0026thinsp;=\u0026thinsp;107) are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no significant differences between the groups in terms of age (p\u0026thinsp;=\u0026thinsp;0.101), sex (p\u0026thinsp;=\u0026thinsp;0.942), BMI (p\u0026thinsp;=\u0026thinsp;0.481), surgery duration (p\u0026thinsp;=\u0026thinsp;0.141), or intraoperative blood loss (p\u0026thinsp;=\u0026thinsp;0.306).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the control and experimental groups [Median (Q1,Q3)]. Q1, Q3: Represent the first quartile (25th percentile) and third quartile (75th percentile), respectively. BMI: Body Mass Index. Time: Represents the duration of surgery in minutes. Blood: Represents the volume of blood loss during surgery in milliliters.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;219)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.942\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94 (88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (39, 47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.5 (40, 47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (37.5, 46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (20, 23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (20, 23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (20, 23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (86, 98.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (85, 96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95 (87, 99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood (Ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (20, 40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (20, 46.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (20, 35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCalcium and parathyroid hormone levels at different time points in both study groups [Median (Q1, Q3)].\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;219)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCa0 (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.33 (2.30, 2.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.32 (2.29, 2.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.34 (2.3, 2.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCa1 (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.19 (2.01, 2.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.06 (1.99, 2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.22 (2.15, 2.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCa2 (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.25 (2.21, 2.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.22 (2.13, 2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.29 (2.23, 2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH0 (pg/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (39, 44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.5 (39, 44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (38, 45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.754\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH1 (pg/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (27, 37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (25, 34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (30, 39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTH2 (pg/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (30, 39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (27, 37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (33, 40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eQ1, Q3: Represent the first quartile (25th percentile) and third quartile (75th percentile), respectively. Ca0: Pre-operative calcium levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCa1: Calcium levels one day post-surgery.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCa2: Calcium levels one week post-surgery.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003ePTH0: Pre-operative parathyroid hormone (PTH) levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003ePTH1: PTH levels one day post-surgery.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003ePTH2: PTH levels one week post-surgery.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePathological Lymph Node Counts Post-Surgery\u003c/h2\u003e \u003cp\u003eThe Mann-Whitney U test was used to compare the pathological lymph node counts between the control and experimental groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The experimental group had a higher mean rank (135.83) compared to the control group (84.12) ( Z = -6.064, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The higher lymph node count in the experimental group implies a more comprehensive removal of affected lymph nodes, which may contribute to reducing the risk of recurrence and improving overall patient outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMann-whitney U test results for pathological lymph Node counts post-surgery between the two study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean ranks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSum of ranks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWilcoxon\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMethod (total)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e136.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14635.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3127.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9455.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-6.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e84.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9455.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMethod 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5185.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e550.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2441.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-6.825\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2441.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMethod 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1424.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e125.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e720.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-5.285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e720.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMethod 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e323.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e19.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e172.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-3.957\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e172.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eThe surgical method used. (method total: the total three below Methods. 1: Total thyroidectomy with unilateral level VI lymph node dissection. Method 2: Total thyroidectomy with bilateral level VI lymph node dissection.Method. 3: Total thyroidectomy with bilateral level VI lymph node dissection and unilateral lateral neck lymph node dissection.)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNumber: The number of cases in each group.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eMean Rank: The average rank of lymph nodes removed for each group.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eSum of Ranks: The sum of ranks of lymph nodes removed for each group.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eWilcoxon W: The Wilcoxon rank-sum test statistic, representing the cumulative rank sum of the groups.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003ez-value: The standardized test statistic, used to determine the significance of the difference between groups.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eP-value: The significance level (P-value).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eSignificant differences were observed in the incidence of numbness and twitching (χ\u0026sup2; = 7.564, p\u0026thinsp;=\u0026thinsp;0.006) and in the pathological parathyroid gland count (χ\u0026sup2; = 11.885, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between the control and experimental groups. The use of nano-carbon suspension in the experimental group facilitated better visualization during surgery, thereby reducing the likelihood of inadvertent resection of the gland and surrounding tissues. Other complications, such as hoarseness, lymphatic leakage, hematoma, and coughing, did not differ significantly between the groups (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of complication between the two study groups [n(%)]. *Fisher\u0026rsquo;s exact text. n(%), cases and their percentages.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStatue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal cases (n\u0026thinsp;=\u0026thinsp;219)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl case (n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperimental case (n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e155 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e82 (76.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHoarseness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.930\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e205 (93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e105 (93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100 (93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumbness and twitching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e196 (89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e94 (83.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e102 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLymphatic leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.719\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e204 (93.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e105 (93.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e99 (92.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e214 (97.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e109 (97.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e105 (98.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCoughing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e212 (96.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e108 (96.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e104 (97.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePathological Parathyroid Gland Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e186 (84.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86 (76.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100 (93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCalcium and PTH Levels\u003c/h2\u003e \u003cp\u003eThe mixed effects model analysis of calcium levels is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The intercept, representing the baseline calcium level, was 2.031 (95% CI: -15.459, 19.522). There were no significant effects of time on calcium levels at Post-Op Week 1 (p\u0026thinsp;=\u0026thinsp;0.886) or Pre-Op (p\u0026thinsp;=\u0026thinsp;0.801). The group variable (experimental vs. control) and its interaction with Post-Op Week 1 were also not significant (p\u0026thinsp;=\u0026thinsp;0.989 and p\u0026thinsp;=\u0026thinsp;0.230, respectively). The variance attributed to the group factor was 78.930, indicating variability between groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCalcium levels results of the mixed effects model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% confidence Interval\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.924\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.820\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-15.459, 19.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime [T.Post-Op Week 1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-2.157, 2.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime [T.Pre-Op]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-2.027, 2.627\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.621\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-24.561, 24.915\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup [T.Post-Op Week 1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.698\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.291, 5.366\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT.Pre-Op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.698\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-3.500, 3.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup Var\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78.930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eIntercept: The baseline level of the calcium levels when all predictors are at their reference levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eTime [T.Post-Op Week 1]: Effect of post-operative week 1 on the calcium levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eTime [T.Pre-Op]: Effect of pre-operation time on the calcium levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup: Effect of the group on the calcium levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup [T.Post-Op Week 1]: Interaction effect of group and post-operative week 1 on the calcium levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eT.Pre-Op: Effect of the pre-operation period the calcium levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup Var: Variance attributed to the grouping factor.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eThe 95% confidence interval provides a range within which the true effect size is expected to fall with 95% confidence.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mixed effects model results for PTH levels are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. The intercept, representing the baseline PTH level, was 27.134 (95% CI: 11.756, 42.512). PTH levels were significantly affected by time at Post-Op Week 1 (p\u0026thinsp;=\u0026thinsp;0.013) and Pre-Op (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating significant changes in PTH levels during these periods. The group variable (p\u0026thinsp;=\u0026thinsp;0.561) and its interaction with Post-Op Week 1 (p\u0026thinsp;=\u0026thinsp;0.759) were not significant. The variance attributed to the group factor was 61.014, indicating moderate variability between groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParathyroid hormone (PTH) levels results of the mixed effects model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% Confidence Interval\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.458\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.756, 42.512\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime [T.Post-Op Week 1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.481\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.543, 4.635\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime [T.Pre-Op]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.204, 16.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.582\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-15.295, 28.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup [T.Post-Op Week 1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-2.469, 3.384\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-Op\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-5.633\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.772\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-8.560, -2.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup Var\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eThe table presents the results of the mixed effects model.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eIntercept: The baseline level of the PTH levels when all predictors are at their reference levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eTime [T.Post-Op Week 1]: Effect of post-operative week 1 on the PTH levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eTime [T.Pre-Op]: Effect of pre-operation time on the PTH levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup: Effect of the group on the PTH levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup [T.Post-Op Week 1]: Interaction effect of group and post-operative week 1 on the PTH levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eT.Pre-Op: Effect of the pre-operation period on the PTH levels.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup Var: Variance attributed to the grouping factor.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eThe 95% confidence interval provides a range within which the true effect size is expected to fall with 95% confidence.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCalcium levels over time by group are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Group 1 (experimental group) exhibited a notable increase in calcium levels at Post-Op Week 1 compared to Group 0 (control group), suggesting an improvement due to the intervention. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e depicts the changes in PTH levels over time by group. Both groups showed a decrease in PTH levels on Post-Op Day 1, followed by an increase at Post-Op Week 1. Group 0 demonstrated a more pronounced decline and subsequent recovery in PTH levels compared to Group 1, indicating differing physiological responses to surgery between the groups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurgical and postoperative outcomes\u003c/h2\u003e \u003cp\u003eThe number of lymph nodes dissected, postoperative lymph node recurrence, surgical method, surgery duration, intraoperative blood loss, parathyroid gland function, and postoperative pathology findings were compared between the groups. The experimental group, which utilized nano-carbon suspension as a marker, exhibited superior surgical outcomes compared to the control group. Postoperative evaluations of symptoms such as hoarseness, coughing, wound hematoma, and lymphatic leakage revealed no significant differences between the groups, except for a notably lower incidence of numbness and twitching, as well as a significantly reduced pathological parathyroid gland count in the experimental group.\u003c/p\u003e \u003cp\u003eThese findings suggest that the use of nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for PTC significantly improves the identification and preservation of parathyroid glands, reducing the incidence of related complications compared to the control group.\u003c/p\u003e \u003cp\u003eRecurrence cases of thyroid cancer post-surgery\u003c/p\u003e \u003cp\u003eRecurrence rates of thyroid cancer post-surgery were compared between the control and experimental groups at 1 month, 6 months, and 12 months (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The experimental group, which utilized nano-carbon suspension, demonstrated significantly fewer recurrences at 12 months compared to the control group (χ\u0026sup2; = 4.231, p\u0026thinsp;=\u0026thinsp;0.040). No significant differences were observed at 1 month or 6 months. These findings suggest that the use of nano-carbon suspension in the experimental group yielded a favorable outcome, reducing the recurrence rate of thyroid cancer over a 12-month period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRecurrence cases of thyroid cancer post-surgery at one month, six months, and twelve months [n(%)]. *Fisher\u0026rsquo;s exact text. n(%), cases and their percentages.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl case\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperimental case\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOne Month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110 (98.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e106 (99.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSix Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.334*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105 (93.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104(97.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTwelve Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e102 (95.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the clinical significance of using nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for patients with PTC. Our findings demonstrate that the use of nano-carbon suspension significantly improves the identification of parathyroid glands, thereby enhancing surgical precision and reducing the incidence of postoperative numbness and twitching as well as the misidentification of parathyroid glands as pathological.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEnhanced Identification and Preservation of Parathyroid Glands\u003c/h2\u003e \u003cp\u003eThe nano-carbon suspension's high affinity for lymphatic tissues provides a distinct visual contrast, as demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e. This enhanced visibility is crucial for preserving the delicate parathyroid glands during extensive neck dissections\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. The clear delineation between the parathyroid glands and surrounding tissues helps surgeons avoid inadvertent damage, significantly reducing the incidence of postoperative numbness and twitching, and the misidentification of parathyroid glands as pathological, thus minimizing the risk of postoperative complications such as hypocalcemia\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. These findings align with previous studies \u003csup\u003e[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e reporting similar benefits of using nano-carbon in other surgical contexts.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePathological Parathyroid Gland Count\u003c/h2\u003e \u003cp\u003eOur study also showed a significant reduction in the pathological parathyroid gland count in the experimental group compared to the control group (6.5% vs. 23.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This result underscores the effectiveness of nano-carbon suspension in preserving parathyroid glands, as the lower pathological parathyroid gland count indicates fewer instances of inadvertent resection of these glands\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The ability to better preserve parathyroid glands during surgery is a critical advantage, reducing the risk of hypoparathyroidism and associated complications\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCalcium and PTH Levels\u003c/h2\u003e \u003cp\u003eThe results from our mixed effects models for calcium and PTH levels further underscore the benefits of nano-carbon use. Although baseline calcium levels were comparable between the groups, the experimental group exhibited more controlled and predictable calcium level maintenance postoperatively\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. This suggests that nano-carbon marking can enhance postoperative calcium homeostasis, thereby decreasing the likelihood of transient or permanent hypoparathyroidism. Similarly, PTH levels showed significant changes across different time points, particularly in the experimental group. The ability to maintain more stable PTH levels in the nano-carbon group underscores the suspension's role in facilitating more precise surgical interventions, likely due to better preservation of parathyroid tissue\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImpact on Complications and Recurrence\u003c/h2\u003e \u003cp\u003eOne notable finding is the comparable rate of complications between the experimental and control groups. Despite the additional step of nano-carbon injection, there was no increase in intraoperative or postoperative complications. The rates of symptoms such as hoarseness, coughing, hematoma, and lymphatic leakage were similar across both groups, indicating that nano-carbon use does not introduce additional risks\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. However, the experimental group showed a significant reduction in the incidence of numbness and twitching, and a lower misidentification rate of parathyroid glands, highlighting the benefits of nano-carbon in reducing specific complications\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Furthermore, the significantly lower rate of postoperative lymph node recurrence in the experimental group suggests that the use of nano-carbon suspension may improve oncological outcomes in PTC surgeries. This aligns with previous studies indicating that enhanced visibility of surgical landmarks can lead to more thorough dissections without compromising oncological efficacy\u003csup\u003e[\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eWhile this study provides robust evidence supporting the use of nano-carbon suspension, several limitations must be acknowledged. The retrospective design and single-center setting may limit the generalizability of the findings. Additionally, long-term follow-up is necessary to fully assess the impact of nano-carbon use on recurrence rates and long-term parathyroid function.\u003c/p\u003e \u003cp\u003eMoreover, the extended time span of the study might have influenced the results due to advancements in surgical techniques and equipment, which likely contributed to the increased number of lymph nodes dissected and reduced incidence of parathyroid gland injury. Future studies should account for these variables to isolate the specific impact of nano-carbon suspension.\u003c/p\u003e \u003cp\u003eFuture research should focus on prospective multicenter trials to validate these findings across diverse populations and surgical settings. Additionally, exploring the molecular mechanisms underlying nano-carbon's selective affinity for lymphatic tissues could lead to further refinements in its application.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, the use of nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for PTC enhances the identification and preservation of parathyroid glands, leading to improved surgical precision and significantly reducing the incidence of specific complications such as numbness and twitching without increasing the overall risk of complications. These findings support the integration of nano-carbon suspension as a standard practice in thyroid cancer surgeries to optimize patient outcomes.\u003c/p\u003e "},{"header":"Methods and materials","content":"\u003ch2\u003eStudy design and patients\u003c/h2\u003e\u003cp\u003eThis study was approved by the hospital's medical ethics committee (approval number: NSYKYLL-2024-61), and informed consent was obtained from all participants and/or their legal guardians. All methods were performed in accordance with relevant guidelines and regulations.\u003c/p\u003e\u003cp\u003eThis retrospective study analyzed 219 patients diagnosed with papillary thyroid carcinoma (PTC) who underwent total thyroidectomy with cervical lymph node dissection at the Ningde Municipal Hospital affiliated with Fujian Medical University between March 2014 and March 2018. Inclusion criteria were: (1) preoperative imaging and/or fine-needle aspiration biopsy confirming PTC with lymph node metastasis; (2) initial thyroid surgery involving total thyroidectomy with lymph node dissection; (3) absence of other diseases affecting blood calcium and parathyroid hormone (PTH) levels. Exclusion criteria were: (1) history of thyroid or other neck surgeries; (2) inability to comply with long-term follow-up.\u003c/p\u003e\u003cp\u003ePatients were divided into two groups: the control group (n = 112) included patients without nono-carbon suspension between March 2014 and February 2016; the experimental group (n = 107) included patients with nono-carbon suspension as a marker during surgery between March 2016 and March 2018.\u003c/p\u003e\u003ch2\u003eSurgical Procedure\u003c/h2\u003e\u003cp\u003eUnder general anesthesia, an incision was made along the anterior cervical white line, and the anterior neck muscles were slightly retracted to expose the thyroid gland and its false capsule. Care was taken to maintain the integrity of the thyroid capsule. The thyroid lobes were exposed, and nano-carbon suspension was injected in the experimental group. Each lobe received nano-carbon suspension (Canaline, Chongqing Laimei Pharmaceutical Co., Ltd., H20041829, 1 mL:50 mg) divided into two points (approximately 0.1 mL per point). Aspiration was performed prior to injection to avoid intravascular administration, followed by gauze compression for 1 minute. After 3–5 minutes, the thyroid and surrounding lymph nodes appeared black-stained (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe thyroid was explored, and an ultrasonic scalpel was used to cut the thyroid isthmus and remove the affected lobe. Once intraoperative frozen section pathology confirmed PTC, total thyroidectomy and central compartment (Level VI) lymph node dissection were performed. The dissection boundaries for the central compartment were the hyoid bone superiorly, suprasternal notch inferiorly, and common carotid arteries laterally, encompassing the perithyroidal, periesophageal, peritracheal, and recurrent laryngeal nerve lymph nodes.\u003c/p\u003e\u003cp\u003eFor patients with preoperatively confirmed lateral neck lymph node metastasis, lateral neck lymph node dissection was added, including Levels II-V from the digastric muscle superiorly to the clavicle inferiorly, bordered medially by the carotid sheath and laterally by the anterior border of the trapezius muscle. The control group underwent a similar surgical procedure without the use of nano-carbon. All surgeries were performed by the same surgical team.\u003c/p\u003e\u003ch2\u003eObservational Parameters\u003c/h2\u003e\u003cp\u003eThe study compared the two groups based on age, sex, body mass index (BMI), surgical method, surgery duration, and intraoperative blood loss. Preoperative, postoperative day 1, and postoperative week 1 blood calcium and PTH levels were measured. Blood calcium levels were measured using an automated analyzer (e.g., Beckman Coulter AU5800) with a reference range of 2.15–2.50 mmol/L. PTH levels were determined using a chemiluminescent immunoassay (e.g., Roche Elecsys PTH assay) with a reference range of 15–65 pg/mL.\u003c/p\u003e\u003cp\u003eThe average number of lymph nodes retrieved (divided into unilateral Level VI, bilateral Level VI, and unilateral lateral neck) and the number of parathyroid glands identified were calculated. Postoperative symptoms such as facial, lip, or extremity paresthesia, numbness, tetany, and twitching, as well as hoarseness, coughing, hematoma, and lymphatic leakage, were evaluated.\u003c/p\u003e\u003cp\u003eReference values and methods for calcium and PTH measurements are critical for accurate interpretation of results. Automated analyzers and chemiluminescent immunoassays provide reliable and reproducible results, essential for assessing the impact of nano-carbon suspension on postoperative calcium and PTH levels.\u003c/p\u003e\u003cp\u003ePostoperative follow-up included thyroid and cervical lymph node ultrasound examinations at 1, 6, and 12 months. Fine-needle aspiration biopsy was performed if lymph node recurrence was suspected.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Nano-carbon suspension injection showing clear contrast between the parathyroid glands and surrounding tissues.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was conducted using the Statistical Package for Social Sciences (SPSS) Version 22.0 (IBM Corp., Armonk, NY, USA), the R package “CBCgrps”\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, and Python 3.7. This comprehensive approach ensured the reliability and reproducibility of the results. The Shapiro–Wilk test assessed the distribution patterns of the variables in both study groups, revealing non-normal distributions. Therefore, results were presented as median values and interquartile ranges (IQRs). For the analysis of categorical data or proportions across the two groups, the Chi-square test or Fisher’s exact test was utilized, depending on the suitability of the data. Baseline characteristics of study participants were summarized using descriptive statistics. Continuous variables not following a normal distribution were presented as median (Q1, Q3). For categorical variables, frequencies and percentages were reported. The Mann–Whitney U test was employed to compare continuous variables between the groups, as the data did not follow a normal distribution. To analyze calcium and PTH levels over different time points, a mixed effects model was used, accounting for the repeated measures design of the study.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eConflict of interest\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003ch2\u003eFunding information\u003c/h2\u003e \u003cp\u003eFinancial support from the Fujian Natural Science Foundation, China (2021J011164).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD-X. L. Conceptualized and designed the study, performed the surgeries, and contributed to manuscript drafting and critical revision. X-B. Z. Assisted with the surgeries, managed patient follow-up, and contributed to the acquisition of clinical data. Y. L. Supervised the overall study, helped with data interpretation, and provided critical revisions of the manuscript for important intellectual content. W-D. L. and G-J. C. Reviewed the literature,ensured ethical compliance, and assisted in manuscript preparation. Y. Z. Provided technical support for the use of nano-carbon suspension and helped with the visualization of parathyroid glands during surgeries. S-Y. Z. Conducted the data collection, statistical analysis, and interpretation of the results. Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBISCHOFF L A, GANLY I, FUGAZZOLA L, et al. Molecular Alterations and Comprehensive Clinical Management of Oncocytic Thyroid Carcinoma: A Review and Multidisciplinary 2023 Update [J]. JAMA Otolaryngol Head Neck Surg, 2024, 150(3): 265\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLODERER T, BONATI E, DONATO V, et al. Malignancy risk in Bethesda class IV thyroid nodules in an iodine deficient region [J]. Gland Surg, 2023, 12(7): 884\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLI X, YAN L, XIAO J, et al. Long-Term Outcomes and Risk Factors of Radiofrequency Ablation for T1N0M0 Papillary Thyroid Carcinoma [J]. JAMA Surg, 2024, 159(1): 51\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKWON O, LEE S, BAE J S. Risk factors associated with high-risk nodal disease in patients considered for active surveillance of papillary thyroid microcarcinoma without extrathyroidal extension [J]. Gland Surgery, 2023, 12(9): 1179.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLIU J, XU C, WANG R, et al. Do carbon nanoparticles really improve thyroid cancer surgery? A retrospective analysis of real-world data [J]. World J Surg Oncol, 2020, 18(1): 84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKARAHAN S N, TOPRAK S, CELIK B, et al. Impact of Indocyanine Green Angiography on Postoperative Parathyroid Function: A Propensity Score Matching Study [J]. Journal of Clinical Medicine, 2024, 13(11): 3038.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWANG L, YANG D, LV J Y, et al. Application of carbon nanoparticles in lymph node dissection and parathyroid protection during thyroid cancer surgeries: a systematic review and meta-analysis [J]. Onco Targets Ther, 2017, 10: 1247\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKOIMTZIS G, STEFANOPOULOS L, ALEXANDROU V, et al. The Role of Carbon Nanoparticles in Lymph Node Dissection and Parathyroid Gland Preservation during Surgery for Thyroid Cancer: A Systematic Review and Meta-Analysis [J]. Cancers (Basel), 2022, 14(16).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWANG Z, BO H, XU Y, et al. Application of carbon nanoparticles combined with refined extracapsular anatomy in endoscopic thyroidectomy [J]. Front Endocrinol (Lausanne), 2023, 14: 1131947.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZHOU J, WU Z, XU H, et al. Nano-Carbon-Based Application of Parecoxib Sodium Combined with Hydromorphone in Preventing Anesthesia Hyperalgesia Caused by Remifentanil after Thyroidectomy [J]. Cell Mol Biol (Noisy-le-grand), 2022, 68(3): 213\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZHANG Z, GAYLE A A, WANG J, et al. Comparing baseline characteristics between groups: an introduction to the CBCgrps package [J]. Ann Transl Med, 2017, 5(24): 484.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBAJ J, SITARZ R, ŁOKAJ M, et al. Preoperative and Intraoperative Methods of Parathyroid Gland Localization and the Diagnosis of Parathyroid Adenomas [J]. Molecules, 2020, 25(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRAO S S, RAO H, MOINUDDIN Z, et al. Preservation of parathyroid glands during thyroid and neck surgery [J]. Frontiers in Endocrinology, 2023, 14: 1173950.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTJAHJONO R, NGUYEN K, PHUNG D, et al. Methods of identification of parathyroid glands in thyroid surgery: a literature review [J]. ANZ Journal of Surgery, 2021, 91(9): 1711\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHE J, SUN P, LIN J, et al. Application of carbon nanoparticles in endoscopic thyroid cancer surgery: a systematic review and meta-analysis [J]. Frontiers in Surgery, 2024, 10: 1283573.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQIN X, LUO J, MA J, et al. Prospective cohort study of parathyroid function and quality of life after total thyroidectomy for thyroid cancer: robotic surgery vs. open surgery [J]. International Journal of Surgery, 2023, 109(12): 3974\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGULATI S, CHUMBER S, PURI G, et al. Multi-modality parathyroid imaging: A shifting paradigm [J]. World J Radiol, 2023, 15(3): 69\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZHAO J, WANG J, CHENG R, et al. Safety and effectiveness of carbon nanoparticles suspension-guided lymph node dissection during thyroidectomy in patients with thyroid papillary cancer: a prospective, multicenter, randomized, blank-controlled trial [J]. Frontiers in Endocrinology, 2024, 14: 1251820.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXIE T, FU Y, ZHANG J, et al. Clinical value of carbon nanoparticles in the identification and preservation of parathyroid glands in situ in papillary thyroid carcinoma [J]. Indian Journal of Surgery, 2022: 1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHE J, SUN P, LIN J, et al. Application of carbon nanoparticles in endoscopic thyroid cancer surgery: a systematic review and meta-analysis [J]. Front Surg, 2023, 10: 1283573.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMA J J, ZHANG D B, ZHANG W F, et al. Application of Nanocarbon in Breast Approach Endoscopic Thyroidectomy Thyroid Cancer Surgery [J]. J Laparoendosc Adv Surg Tech A, 2020, 30(5): 547\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXU S, LI Z, XU M, et al. The role of carbon nanoparticle in lymph node detection and parathyroid gland protection during thyroidectomy for non-anaplastic thyroid carcinoma-a meta-analysis [J]. Plos one, 2020, 15(11): e0223627.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYIN C, WANG X, SUN S. Reduction in postoperative hypoparathyroidism following carbon nanoparticle suspension injection combined with parathyroid gland vasculature preservation [J]. J Int Med Res, 2020, 48(1): 300060519866606.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePENG S-J, YANG P, DONG Y-M, et al. Potential protection of indocyanine green on parathyroid gland function during near-infrared laparoscopic-assisted thyroidectomy: A case report and literature review [J]. World Journal of Clinical Cases, 2020, 8(21): 5480.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLI J, DENG X, WANG L, et al. Clinical application of carbon nanoparticles in lymphatic mapping during colorectal cancer surgeries: A systematic review and meta-analysis [J]. Digestive and Liver Disease, 2020, 52(12): 1445\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZHU C, WANG J, WU Q, et al. Safety and efficacy of carbon nanoparticle-labeled lymph node dissection in radical resection of gastric cancer: a systematic review and meta-analysis [J]. Technology in Cancer Research \u0026amp; Treatment, 2023, 22: 15330338231154094.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Papillary thyroid carcinoma, Nano-carbon suspension, Parathyroid gland preservation, Hypocalcemia, Parathyroid hormone, Postoperative complications","lastPublishedDoi":"10.21203/rs.3.rs-4700131/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4700131/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study evaluates the clinical significance of using nano-carbon suspension in total thyroidectomy with cervical lymph node dissection for papillary thyroid carcinoma (PTC). The objective is to assess the efficacy of nano-carbon in enhancing parathyroid gland preservation, reducing postoperative complications, and improving surgical precision. A retrospective analysis of 219 PTC patients who underwent total thyroidectomy and cervical lymph node dissection from March 2014 to March 2018 was conducted. Patients were divided into two groups: control (n\u0026thinsp;=\u0026thinsp;112) without nano-carbon suspension and experimental (n\u0026thinsp;=\u0026thinsp;107) with nano-carbon suspension. Comparative analyses included demographics, surgical parameters, postoperative calcium and parathyroid hormone (PTH) levels, number of lymph nodes dissected, and incidence of complications. Baseline characteristics, including age, sex, and BMI, were comparable between the experimental and control groups, with no statistically significant differences observed. Postoperative calcium levels were significantly more stable in the experimental group, with median levels of 2.22 mmol/L on day 1 compared to 2.06 mmol/L in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and 2.29 mmol/L at week 1 compared to 2.22 mmol/L in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). PTH levels were also higher in the experimental group (35 pg/mL on day 1 vs. 28 pg/mL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 37 pg/mL at week 1 vs. 30 pg/mL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The experimental group had more lymph nodes dissected (median 135.83 vs. 84.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a lower pathological parathyroid gland count (6.5% vs. 23.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Postoperative numbness and twitching were reduced (4.7% vs. 16.1%, p\u0026thinsp;=\u0026thinsp;0.006), and the recurrence rate at 12 months was lower (4.7% vs. 12.5%, p\u0026thinsp;=\u0026thinsp;0.040). Nano-carbon suspension in thyroidectomy with cervical lymph node dissection for PTC enhances parathyroid gland preservation, improves surgical precision, and reduces specific postoperative complications, advocating its standard use in thyroid cancer surgeries to optimize patient outcomes.\u003c/p\u003e","manuscriptTitle":"Enhancing parathyroid preservation in papillary thyroid carcinoma surgery using nano-carbon suspension","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 20:28:53","doi":"10.21203/rs.3.rs-4700131/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-19T07:37:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-18T23:43:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-17T23:05:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-15T20:31:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87763555805357992393396530603902268091","date":"2024-08-10T06:59:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296783811719077847237064637605742315111","date":"2024-08-09T11:46:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98374059033891772230886543723543404562","date":"2024-08-09T11:45:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210147914213777948333599944459201828313","date":"2024-08-07T22:11:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196947332653678786805243732881243445946","date":"2024-08-07T18:42:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"215354787225564292404191106820380626552","date":"2024-08-05T13:17:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-02T16:49:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-02T12:40:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-12T10:03:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-09T04:29:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-07-07T12:13:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6c17a1a7-3033-41f6-9174-62905c9d09cf","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":35234183,"name":"Health sciences/Biomarkers"},{"id":35234184,"name":"Health sciences/Medical research"},{"id":35234185,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2024-10-28T16:10:06+00:00","versionOfRecord":{"articleIdentity":"rs-4700131","link":"https://doi.org/10.1038/s41598-024-76126-1","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-10-21 15:57:00","publishedOnDateReadable":"October 21st, 2024"},"versionCreatedAt":"2024-08-09 20:28:53","video":"","vorDoi":"10.1038/s41598-024-76126-1","vorDoiUrl":"https://doi.org/10.1038/s41598-024-76126-1","workflowStages":[]},"version":"v1","identity":"rs-4700131","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4700131","identity":"rs-4700131","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}