Skip to main content

Advertisement

SpringerLink
Log in

Pre-incisional, trans-isthmic injection of indocyanine green for lymph node mapping during the transoral endoscopic thyroidectomy vestibular approach

  • Original Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

Abstract

Indocyanine green (ICG) is a useful tracer for lymph node mapping and retrieval. However, during endoscopic surgery, it is challenging to administer ICG into the thyroid without spillage. We developed a simple technique of delivering ICG, thereby preventing leakage. Patients who underwent the transoral endoscopic thyroidectomy were retrospectively reviewed. In 20 patients, who constituted the ICG group, 0.1 mL ICG was injected into the peri-tumoral space under ultrasound guidance, soon after the patients received general anesthesia. Patients with papillary thyroid carcinoma who did not receive the ICG injection comprised the control group (n = 43). The location, size, and number of harvested lymph nodes were recorded in conjunction with parathyroid-related parameters. No ICG spillage occurred in the ICG group, and 76 ICG-stained lymph nodes were detected in the pretracheal (57.9%), paratracheal (25.0%), and prelaryngeal regions (17.1%). The ICG group demonstrated a significantly higher number of total (5.3 vs 2.1) and metastatic (1.5 vs 0.6) lymph nodes, a larger metastatic deposit in the positive node (3.5 mm vs 1.6 mm), and a higher rate of pathologically node-positive disease (70.0% vs 27.9%) than did the control group. The postoperative calcium level (7.8 mg/dL vs 7.2 mg/dL) was also higher in the ICG group. Pre-incisional, trans-isthmic injection of ICG under ultrasound guidance is a simple technique to prevent the leakage of ICG. Under fluorescence imaging, an adequate number of lymph nodes can be harvested for examination, which may assist in intraoperative decision-making.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Kim DH, Kim SH, Jung J, Kim SW, Hwang SH (2022) Indocyanine green fluorescence for parathyroid gland identification and function prediction: systematic review and meta-analysis. Head Neck 44:783–791. https://doi.org/10.1002/hed.26950

    Article  PubMed  Google Scholar 

  2. Spartalis E, Ntokos G, Georgiou K, Zografos G, Tsourouflis G, Dimitroulis D, Nikiteas NI (2020) Intraoperative indocyanine green (ICG) angiography for the identification of the parathyroid glands: current evidence and future perspectives. In Vivo 34:23–32. https://doi.org/10.21873/invivo.11741

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Kim WW, Choi JA, Lee J, Jung JH, Park HY (2018) Fluorescence imaging-guided robotic thyroidectomy and central lymph node dissection. J Surg Res 231:297–303. https://doi.org/10.1016/j.jss.2018.05.071

    Article  PubMed  Google Scholar 

  4. Zhang X, Shen YP, Li JG, Chen G (2019) Clinical feasibility of imaging with indocyanine green combined with carbon nanoparticles for sentinel lymph node identification in papillary thyroid microcarcinoma. Medicine (Baltimore) 98:e16935. https://doi.org/10.1097/MD.0000000000016935

    Article  CAS  PubMed  Google Scholar 

  5. Zhang X, Li JG, Zhang SZ, Chen G (2020) Comparison of indocyanine green and carbon nanoparticles in endoscopic techniques for central lymph nodes dissection in patients with papillary thyroid cancer. Surg Endosc 34:5354–5359. https://doi.org/10.1007/s00464-019-07326-4

    Article  PubMed  Google Scholar 

  6. Zhang D, Wang T, Dionigi G, Fu Y, Zhang J, Zhao Y, Li J, Sun H (2019) Application of carbon nanoparticles in endoscopic thyroidectomy via bilateral areola approach: total thyroidectomy plus central lymph node dissection. J Laparoendosc Adv Surg Tech A 29:1038–1041. https://doi.org/10.1089/lap.2019.0102

    Article  PubMed  Google Scholar 

  7. Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, Richmon JD (2018) Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc 32:456–465. https://doi.org/10.1007/s00464-017-5705-8

    Article  PubMed  Google Scholar 

  8. Liang TJ, Tsai CY, Chen IS (2020) Foley balloon facilitates creation of working space in transoral thyroidectomy. World J Surg 44:1514–1517. https://doi.org/10.1007/s00268-019-05360-w

    Article  PubMed  Google Scholar 

  9. Liang TJ, Chen IS, Liu SI (2022) Working space creation in transoral thyroidectomy: pearls and pitfalls. Cancers (Basel) 14(4):1031. https://doi.org/10.3390/cancers14041031

    Article  CAS  PubMed  Google Scholar 

  10. Orloff LA, Noel JE, Stack BC Jr, Russell MD, Angelos P, Baek JH, Brumund KT, Chiang FY, Cunnane MB, Davies L, Frasoldati A, Feng AY, Hegedüs L, Iwata AJ, Kandil E, Kuo J, Lombardi C, Lupo M, Maia AL, McIver B, Na DG, Novizio R, Papini E, Patel KN, Rangel L, Russell JO, Shin J, Shindo M, Shonka DC Jr, Karcioglu AS, Sinclair C, Singer M, Spiezia S, Steck JH, Steward D, Tae K, Tolley N, Valcavi R, Tufano RP, Tuttle RM, Volpi E, Wu CW, Abdelhamid Ahmed AH, Randolph GW (2022) Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: an international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association. Head Neck 44:633–660. https://doi.org/10.1002/hed.26960

    Article  PubMed  Google Scholar 

  11. Ofo E, Thavaraj S, Cope D, Barr J, Kapoor K, Jeannon JP, Oakley R, Lock C, Odell E, Simo R (2016) Quantification of lymph nodes in the central compartment of the neck: a cadaveric study. Eur Arch Otorhinolaryngol 273:2773–2778. https://doi.org/10.1007/s00405-015-3827-y

    Article  PubMed  Google Scholar 

  12. Ji YB, Lee KJ, Park YS, Hong SM, Paik SS, Tae K (2012) Clinical efficacy of sentinel lymph node biopsy using methylene blue dye in clinically node-negative papillary thyroid carcinoma. Ann Surg Oncol 19:1868–1873. https://doi.org/10.1245/s10434-011-2109-1

    Article  PubMed  Google Scholar 

  13. Zhu Y, Lin J, Yan Y, Zheng K, Zhang H, Wu K, Kong L, Chen L, Chen X (2021) Delphian lymph node metastasis is a novel indicator of tumor aggressiveness and poor prognosis in papillary thyroid cancer. J Surg Oncol 123:1521–1528. https://doi.org/10.1002/jso.26380

    Article  PubMed  Google Scholar 

  14. Albers MB, Nordenstrom E, Wohlfahrt J, Bergenfelz A, Almquist M (2020) Sentinel lymph node biopsy in thyroid cancer. World J Surg 44:142–147. https://doi.org/10.1007/s00268-019-05218-1

    Article  PubMed  Google Scholar 

  15. Garau LM, Rubello D, Ferretti A, Boni G, Volterrani D, Manca G (2018) Sentinel lymph node biopsy in small papillary thyroid cancer. A review on novel surgical techniques. Endocrine 62:340–350. https://doi.org/10.1007/s12020-018-1658-5

    Article  CAS  PubMed  Google Scholar 

  16. Yan X, Zeng R, Ma Z, Chen C, Chen E, Zhang X, Cao F (2015) The utility of sentinel lymph node biopsy in papillary thyroid carcinoma with occult lymph nodes. PLoS ONE 10:e0129304. https://doi.org/10.1371/journal.pone.0129304

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Roh JL, Park CI (2008) Sentinel lymph node biopsy as guidance for central neck dissection in patients with papillary thyroid carcinoma. Cancer 113:1527–1531. https://doi.org/10.1002/cncr.23779

    Article  PubMed  Google Scholar 

  18. Garau LM, Rubello D, Muccioli S, Boni G, Volterrani D, Manca G (2020) The sentinel lymph node biopsy technique in papillary thyroid carcinoma: the issue of false-negative findings. Eur J Surg Oncol 46:967–975. https://doi.org/10.1016/j.ejso.2020.02.007

    Article  PubMed  Google Scholar 

  19. Robinson TJ, Thomas S, Dinan MA, Roman S, Sosa JA, Hyslop T (2016) How many lymph nodes are enough? Assessing the adequacy of lymph node yield for papillary thyroid cancer. J Clin Oncol 34:3434–3439. https://doi.org/10.1200/jco.2016.67.6437

    Article  PubMed  PubMed Central  Google Scholar 

  20. Zhou L, Li H, Liang W, Gao C, Chen B (2020) Pretracheal-laryngeal lymph nodes in frozen section predicting contralateral paratracheal lymph nodes metastasis. Eur J Surg Oncol 46:1829–1834. https://doi.org/10.1016/j.ejso.2020.06.048

    Article  PubMed  Google Scholar 

  21. Patel KN, Yip L, Lubitz CC, Grubbs EG, Miller BS, Shen W, Angelos P, Chen H, Doherty GM, Fahey TJ 3rd, Kebebew E, Livolsi VA, Perrier ND, Sipos JA, Sosa JA, Steward D, Tufano RP, McHenry CR, Carty SE (2020) The American Association of Endocrine Surgeons guidelines for the definitive surgical management of thyroid disease in adults. Ann Surg 271:e21–e93. https://doi.org/10.1097/SLA.0000000000003580

    Article  PubMed  Google Scholar 

  22. McAlister ED, Goldstein DP, Rotstein LE (2014) Redefining classification of central neck dissection in differentiated thyroid cancer. Head Neck 36:286–290. https://doi.org/10.1002/hed.23237

    Article  PubMed  Google Scholar 

  23. Liang TJ, Wang NY, Tsai CY, Liu SI, Chen IS (2021) Outcome comparison between endoscopic transoral and bilateral axillo-breast approach thyroidectomy performed by a single surgeon. World J Surg 45:1779–1784. https://doi.org/10.1007/s00268-021-06014-6

    Article  PubMed  Google Scholar 

Download references

Funding

This research received no external funding.

Author information

Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd, Zuoying District, Kaohsiung, 813414, Taiwan

    Tsung-Jung Liang, I-Shu Chen & Shiuh-Inn Liu

  2. School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong Street, Taipei, 112304, Taiwan

    Tsung-Jung Liang & Shiuh-Inn Liu

Authors
  1. Tsung-Jung Liang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. I-Shu Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shiuh-Inn Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

TJL and SIL performed the study design and wrote the manuscript of the paper. TJL collected the data. TJL and ISC performed the statistical analysis. All the authors reviewed the paper.

Corresponding author

Correspondence to Shiuh-Inn Liu.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest.

Research involving human participants and/or animals

The study was approved by the Ethics Committee of Kaohsiung Veterans General Hospital and performed in accordance with the Declaration of Helsinki.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Liang, TJ., Chen, IS. & Liu, SI. Pre-incisional, trans-isthmic injection of indocyanine green for lymph node mapping during the transoral endoscopic thyroidectomy vestibular approach. Updates Surg 75, 2313–2320 (2023). https://doi.org/10.1007/s13304-023-01580-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-023-01580-x

Keywords

Search

Navigation