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Fluorescence imaging to visualize the recurrent laryngeal nerve during thyroidectomy procedures: analysis of 65 cases and 81 nerves

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Abstract

Background

Recurrent laryngeal nerve (RLN) injury after thyroidectomy is relatively common. Locating the RLN prior to thyroid dissection is paramount to avoid injury. We developed a fluorescence imaging system that permits nerve autofluorescence. We aimed to determine the sensitivity and specificity of fluorescence imaging at detecting the RLN relative to thyroid and other background tissue and compared it to white light.

Methods

In this prospective study, 65 patients underwent thyroidectomy from January to April 2022 (16 bilateral thyroid resections) using white and fluorescent light. Fluorescence intensity [relative fluorescence units (RFU)] was recorded for RLN, thyroid, and background. RFU mean, minimum, and maximum values were calculated using Image J software. Thirty randomly selected pairs of white and fluorescent light images were independently reviewed by two examiners to compare RLN detection rate, number of branches, and length and minimum width of nerves visualized. Parametric and nonparametric statistical analysis was performed.

Results

All 81 RNLs observed were visualized more clearly under fluorescence (mean intensity, µ = 134.3 RFU) than either thyroid (µ = 33.7, p < 0.001) or background (µ = 14.4, p < 0.001). Forest plots revealed no overlap between RLN intensity and that of either other tissue. Sensitivity and specificity for RLN were 100%. All 30 RLNs and all 45 nerve branches were clearly visualized under fluorescence, versus 17 and 22, respectively, with white light (both p < 0.001). Visible nerve length was 2.5 × as great with fluorescence as with white light (µ = 1.90 vs. 0.76 cm, p < 0.001).

Conclusions

In 65 patients and 81 nerves, RLN detection was markedly and consistently enhanced with autofluorescence neuro-imaging during thyroidectomy, with 100% sensitivity and specificity.

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Authors and Affiliations

  1. Hospital de Clínicas José de San Martín, Buenos Aires, Argentina

    Fernando Dip & Jorge Falco

  2. ScienceRight Research Consulting Services, London, ON, Canada

    Kevin White

  3. Cleveland Clinic Florida, The Bariatric Institute, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA

    Raul Rosenthal

Authors
  1. Fernando Dip
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  2. Jorge Falco
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  3. Kevin White
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  4. Raul Rosenthal
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Corresponding author

Correspondence to Raul Rosenthal.

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Disclosures

Kevin White is an independent research consultant and statistician who was paid for his participation in this study. No other author received any funding for this study. Fernando Dip and Raul Rosenthal are on the Advisory Board for Axon Imaging Technologies. Fernando Dip is a company stakeholder. Dr. Falco has no potential conflicts of interest to declare.

Ethical approval

This study was conducted according to the Declaration of Helsinki as a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data. Prior to subject enrollment, Institutional Review Board (ethics) approval was received for this study from the Hospital de Clínicas Jose de San Martín where all patients underwent surgery. All patients signed informed patient/participant consent prior to enrollment.

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Dip, F., Falco, J., White, K. et al. Fluorescence imaging to visualize the recurrent laryngeal nerve during thyroidectomy procedures: analysis of 65 cases and 81 nerves. Surg Endosc 38, 1406–1413 (2024). https://doi.org/10.1007/s00464-023-10627-4

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  • DOI: https://doi.org/10.1007/s00464-023-10627-4

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