Less Is More: Advancements in Thyroid Surgery

You can test, in real time, the integrity of the recurrent laryngeal nerves during the operation. — David C. Shonka, Jr., MD

Of course, the fact that the glands autofluoresce even when devascularized is one shortcoming of most existing parathyroid detection systems. The current systems are not able to determine if identified parathyroid glands will be functional after surgery. Indocyanine green (ICG) can be used to assess the function of the parathyroid glands during surgery but requires extra steps and limits the use of near-infrared autofluorescence following administration (In Vivo. doi:10.21873/invivo.11741).

At present, “there is more data supporting the utility of autofluorescence to identify parathyroids during thyroid and parathyroid surgery, at an earlier stage of its introduction, as compared to nerve monitoring,” Dr. Randolph said. “So, I would expect that autofluorescence with cameras and probes will be routinely applied in an even shorter time than it took for nerve monitoring to be widely adopted.”

Cost, however, may be a barrier. “In this cost-conscious healthcare environment, it’s sometimes hard to get hospital systems to buy equipment that cannot be directly reimbursed,” Dr. Karcioglu said.

Nonsurgical Treatment

Advances in the nonsurgical treatment of thyroid conditions are also contributing to a decrease in thyroid surgery. Active surveillance is now a “reasonable treatment option for some very small thyroid cancers in the appropriate clinical setting,” Dr. Shonka said. Energy-based ablation techniques, including laser, radiofrequency, and microwave, can be used to treat benign thyroid nodules and some small cancers, minimizing the need for thyroid surgeries. And, the rapid development of targeted therapies to treat thyroid cancer now offers potential opportunities for cures in cases that would have previously been deemed incurable.

“Multiple clinical trials are currently looking into targeted systemic therapy followed by surgery,” Dr. Shonka said. Evidence to date suggests that neoadjuvant therapy may shrink tumors and perhaps allow physicians to perform less surgery, with improved morbidity and better oncologic outcomes.

Each of these innovations is changing the landscape of thyroid surgery. Right now, otolaryngologists must master and adopt multiple tools and techniques to harness the power of these advances. In the not-so-distant future, these innovations may be combined into an easier-to-use interface, such as a technology-packed “helmet” or “Google Glass-type device,” Dr. Randoph said.

“Right now, we have individual disparate technologies all extending into the surgical space. They’re like individual planks to cross the valley and get us to where we need to be. They need to be melded into one multifunctional interface that will form a steel bridge to get us to the other side,” Dr. Randolph said. “And I think that will happen.” 

Jennifer Fink is a freelance medical writer based in Wisconsin.