Shining a light on the parathyroid glands – literally
November 19, 2020
Every surgery has its own unique challenges. One of the most complex aspects of a thyroidectomy is removing the butterfly-shaped thyroid gland without damaging or removing the tiny parathyroid glands located right next to it.
These four pea-sized glands produce parathyroid hormone (PTH) and are essential to maintaining a proper balance of calcium and phosphorus in the body. Damaging or removing them can lead to hypoparathyroidism, and symptoms such as numbness and tingling, which can progress to cramping and seizures if left untreated.
While our surgeons are experts at locating the parathyroid glands in the neck, it never hurts to have “a second opinion.” Thanks to a new advanced infrared technology, UT Southwestern’s endocrine surgery team can provide that extra confirmation for patients in real-time during the operation.
Fluobeam is a handheld device that uses a laser to illuminate the parathyroid glands, which have a natural “glow,” making them easier to locate and assess before, during, and after surgery.
We can even use it to determine whether a parathyroid gland is viable after a complex thyroidectomy. If it is not, we can auto-transplant the parathyroid gland to a location where it will have better blood supply to avoid complications of hypoparathyroidism.
Our surgeons at UT Southwestern Frisco were the first in Texas to use this advanced technology for parathyroid procedures, and in doing so we are reducing risk levels for our patients.
The most common cause of hypoparathyroidism is complications due to neck surgery. A 2015 NIH study showed that 18% of patients who had a thyroidectomy developed hypoparathyroidism, which typically requires treatment with hormone or calcium supplements. While only 1.9% of the study participants experienced permanent hypoparathyroidism, that is still too many.
3 ways an ‘infrared flashlight’ helps during thyroid surgery
Fluobeam was approved by the U.S. Food and Drug Administration in 2018 to detect parathyroid tissue during thyroidectomy and parathyroid surgery. My colleagues and I use it in three ways:
1. Get the glands to glow
Parathyroid tissue naturally emits a fluorescent glow when exposed to infrared light. This is known as autofluorescence. The device acts like an “infrared flashlight” that we can shine into an incision in the neck to make the parathyroid glands glow.
This approach requires no contrast dye or additional incisions. By detecting the parathyroid glands early in surgery, we can more easily avoid injuring them.
2. Find the blood vessels with dye
A vital part of saving the parathyroid glands is to preserve their blood supply. By combining autofluorescence with indocyanine green (ICG), a dye that we inject to make the blood vessels more visible, we can see and avoid the blood vessels that supply the parathyroid glands during thyroidectomy.
3. Move and regrow damaged parathyroid glands
Before we close the thyroidectomy incision, which generally will range from 4cm to 6cm, we must make sure the blood supply to the parathyroid glands is healthy. We're looking for the parathyroid glands to be pink in color – dark-colored tissue can indicate damaged or dead tissue.
Though we can make this assessment with the naked eye, this is not always accurate. By using the ICG function on the Fluobeam, we can inject dye at the end of the case. Illumination of the parathyroid gland’s blood supply gives us validation that the parathyroid gland indeed has a healthy blood supply.
If, however, the blood vessel to the parathyroid gland does not light up, we know that the particular parathyroid gland does not have a healthy blood supply, and it gives us the opportunity to auto-transplant the de-vascularized tissue to an area with healthy blood supply.
We do this by removing the de-vascularized parathyroid gland and mincing it into small pieces. We then inject this tissue into a muscle in the neck, and the muscle’s robust blood supply will help these parathyroid “seeds” to grow, avoiding postoperative hypoparathyroidism.
When we might use the 'beam' – and when we might not
Fluobeam is most useful during surgeries to correct thyroid conditions such as hyperthyroidism caused by Graves’ disease or thyroid and lymph node removal for thyroid cancer. The parathyroid glands aren’t immediately apparent to the naked eye because they are buried in the thyroid or other surrounding tissue.
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However, Fluobeam is limited when a patient has a cystic thyroid nodule, which can shine just as brightly as a parathyroid gland under infrared light and result in false positives. Additionally, in cases of parathyroid adenoma (a benign tumor), the diseased gland may not light up as well as a healthy gland would.
Technology meets surgical expertise
Fluobeam is not a replacement for experience – our surgeons have been doing successful thyroidectomies for years without the aid of infrared technology.
However, we also know when an advancement in surgical technology and techniques will benefit our patients. I think of Fluobeam as an extra set of eyes in the operating room when it comes to avoiding or transplanting a patient's parathyroid glands.
We’re excited to offer our patients access to this advanced technology. When combined with surgical expertise, we can help more patients avoid surgical complications and return to health quicker.
To visit with a parathyroid or thyroid expert, call 214-645-8300 or request an appointment online.
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