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Publication Open Access Extralaryngeal division of the recurrent laryngeal nerve: A common and asymmetric anatomical variant(AVES [email protected], 2017) Uludaǧ, Mehmet; Yetkin, Gürkan; Oran, Ebru Şen; Aygün, Nurcihan; Celayir, Fevzi; Işgör, Adnan; Uludaǧ, Mehmet, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Yetkin, Gürkan, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Oran, Ebru Şen, Clinic of General Surgery, Bak?rkoy Dr. Sadi Konuk Egitim ve Arast?rma Hastanesi, Istanbul, Turkey; Aygün, Nurcihan, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Celayir, Fevzi, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Işgör, Adnan, Department of General Surgery, Bahçeşehir Üniversitesi, Istanbul, TurkeyObjective: Recognition of extralaryngeal branching of the recurrent laryngeal nerve is crucial because prevention of vocal cord paralysis requires preservation of all branches of the recurrent laryngeal nerve. We assessed the prevalence of extralaryngeal branching of the recurrent laryngeal nerve and the median branching distance from the point of bifurcation to the entry point of the nerve into the larynx. Material and Methods: Prospective operative data on recurrent laryngeal nerve branching were collected from 94 patients who underwent thyroid or parathyroid surgery between September 2011 and May 2012. Results: A total of 161 recurrent laryngeal nerves were examined (82 right, 79 left). Overall, 77 (47.8%) of 161 recurrent laryngeal nerves were bifurcated before entering the larynx. There were 36 (43.9%) branching nerves on the right and 41 (51.9%) branching nerves on the left, and there was no significant difference between the sides in terms of branching (p=0.471). Among 67 patients who underwent bilateral exploration, 28.4% were found to have bilateral branching, 40.3% had unilateral branching, and the remaining 31.3% had no branching. The median branching distance was 15 mm (5-60mm). Conclusion: Extralaryngeal division of recurrent laryngeal nerve is a common and asymmetric anatomical variant. These variations can be easily recognized if the recurrent laryngeal nerve is identified at the level of the inferior thyroid artery and then dissected totally to the entry point of the larynx. Inadvertent division of a branch may lead to vocal cord palsy postoperatively, even when the surgeon believes the integrity of the nerve has been preserved. © 2020 Elsevier B.V., All rights reserved.Publication Open Access Contribution of intraoperative neuromonitoring to the identification of the external branch of superior laryngeal nerve(AVES [email protected], 2017) Aygün, Nurcihan; Uludaǧ, Mehmet; Işgör, Adnan; Aygün, Nurcihan, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Uludaǧ, Mehmet, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Işgör, Adnan, Department of General Surgery, Bahçeşehir Üniversitesi, Istanbul, TurkeyObjective: We evaluated the contribution of intraoperative neuromonitoring to the visual and functional identification of the external branch of the superior laryngeal nerve. Material and Methods: The prospectively collected data of patients who underwent thyroid surgery with intraoperative neuromonitoring for external branch of the superior laryngeal nerve exploration were assessed retrospectively. The surface endotracheal tube-based Medtronic NIM3 intraoperative neuromonitoring device was used. The external branch of the superior laryngeal nerve function was evaluated by the cricothyroid muscle twitch. In addition, contribution of external branch of the superior laryngeal nerve to the vocal cord adduction was evaluated using electromyographic records. Results: The study included data of 126 (female, 103, male, 23) patients undergoing thyroid surgery, with a mean age of 46.2±12.2 years (range, 18-75 years), and 215 neck sides were assessed. Two hundred and one (93.5%) of 215 external branch of the superior laryngeal nerves were identified, of which 60 (27.9%) were identified visually before being stimulated with a monopolar stimulator probe. Eighty-nine (41.4%) external branch of the superior laryngeal nerves were identified visually after being identified with a probe. Although 52 (24.1%) external branch of the superior laryngeal nerves were identified with a probe, they were not visualized. Intraoperative neuromonitoring provided a significant contribution to visual (p<0.001) and functional (p<0.001) identification of external branch of the superior laryngeal nerves. Additionally, positive electromyographic responses were recorded from 160 external branch of the superior laryngeal nerves (74.4%). Conclusion: Intraoperative neuromonitoring provides an important contribution to visual and functional identification of external branch of the superior laryngeal nerves. We believe that it can not be predicted whether the external branch of the superior laryngeal nerve is at risk or not and the nerve is often invisible, thus, intraoperative neuromonitoring may routinely be used in superior pole dissection. Glottic electromyography response obtained via external branch of the superior laryngeal nerve stimulation provides quantifiable information in addition to the simple visualization of the cricothyroid muscle twitch. © 2020 Elsevier B.V., All rights reserved.Publication Open Access Intraoperative Neuromonitoring in Thyroid Surgery: An Efficient Tool to Avoid Bilateral Vocal Cord Palsy(SAGE Publications Ltd, 2021) Kartal, Kinyas; Aygün, Nurcihan; Celayir, Fevzi; Besler, Evren; Çitgez, Bülent; Işgör, Adnan; Uludaǧ, Mehmet; Kartal, Kinyas, Department of General Surgery, Koç Üniversitesi, Istanbul, Turkey; Aygün, Nurcihan, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Celayir, Fevzi, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Besler, Evren, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Çitgez, Bülent, Department of General Surgery, University of Health Sciences, Istanbul, Turkey; Işgör, Adnan, Department of General Surgery, Bahçeşehir Üniversitesi, Istanbul, Turkey; Uludaǧ, Mehmet, Department of General Surgery, University of Health Sciences, Istanbul, TurkeyObjectives: This study aimed to analyze the effects of intraoperative neuromonitoring (IONM) on the prevalence of vocal cord palsy (VCP) in thyroid surgery. Methods: Data from 493 patients (839 nerves at risk [NAR]) who underwent thyroid surgery between July 2014 and May 2016 were retrospectively evaluated. The patients were divided into 2 groups: Group 1 (G1) consisted of patients who underwent surgery without IONM, whereas group 2 (G2) consisted of patients who underwent surgery with IONM. The surgical techniques were identical, and experienced surgeons performed the procedures in both groups. Intraoperative neuromonitoring was performed in compliance with the International Neural Monitoring Guidelines. Results: In total, 211 patients (170 female, 41 male) with 360 NAR were included in G1, and 282 patients (220 female, 62 male) with 479 NAR were included in G2. The number of VCP per NAR in G1 and G2 was 33 (9.2%) and 27 (5.6%), respectively (P =.005). The number of transient VCP per NAR in G1 and G2 was 27 (7.5%) and 23 (4.8%, P =.230), respectively. The number of permanent VCP per NAR in G1 and G2 was 6 (1.7%) and 4 (0.8%, P =.341), respectively. Bilateral VCP was detected in 4 (2.7%) patients in G1, whereas there was no patient with bilateral VCP in G2 (P =.033). Conclusions: Intraoperative neuromonitoring may decrease the incidence of total VCP and prevent the development of bilateral VCP, which has unfavorable results for both patients and health-care professionals. © 2022 Elsevier B.V., All rights reserved.Publication Open Access The effect of strap muscle transection on voice and swallowing changes after thyroidectomy in patients without laryngeal nerve injury(Royal College of Surgeons of England, 2022) Aygün, Nurcihan; Celayir, Fevzi; Işgör, Adnan; Uludaǧ, Mehmet; Aygün, Nurcihan, University of Health Sciences, Istanbul, Turkey; Celayir, Fevzi, University of Health Sciences, Istanbul, Turkey; Işgör, Adnan, Bahçeşehir Üniversitesi, Istanbul, Turkey; Uludaǧ, Mehmet, University of Health Sciences, Istanbul, TurkeyIntroduction Voice and swallowing symptoms are frequently reported after thyroidectomy even without laryngeal nerve injury. We aimed to evaluate the effect of strap muscle transection on voice and swallowing outcome after thyroidectomy. Methods Group 1 (G1) consisted of 17 patients who had their strap muscles transected during thyroidectomy and group 2 (G2) consisted of 17 patients who had their strap muscles preserved during thyroidectomy. None of the patients had laryngeal nerve injury. Voice impairment scores (VIS) and swallowing impairment scores (SIS) were obtained preoperatively and at 1 week and 1, 3 and 6 months postoperatively. Pre- and postoperative vocal cord examinations were performed for all patients. The external branch of the superior laryngeal nerve (EBSLN) was evaluated by intraoperative cricothyroid muscle electromyography. Results There was no significant difference in VIS and SIS between the two groups. At postoperative week 1, the VIS and SIS for each group were above preoperative values (G1: p = 0.005 and p = 0.035, G2: p = 0.031, p = 0.346, for VIS and SIS respectively). The VIS and SIS scores at 6 months postoperatively were significantly lower than those of the first week postoperatively (G1: p = 0.04 and p = 0.001, G2: p = 0.022 and p = 0.034 respectively) and similar to preoperative values (G1: p = 0.924 and p = 0.086, G2: p = 0.822 and p = 0.187 respectively). Conclusion Although voice and swallowing complaints increased in the early postoperative period even without recurrent laryngeal nerve and EBSLN injuries, these symptoms are not related with the strap muscle transection. © 2023 Elsevier B.V., All rights reserved.Publication Open Access Tiroid cerrahisi sonrası hipokalsemi gelişimini etkileyen faktörler(2015) Yetkin, Sıtkı Gürkan; Mihmanlı, Mehmet; Uludağ, Mehmet; Çitgez, Bülent; Aygün, Nurcihan; Besler, Evren; İşgör, Adnan; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Bahçeşehir ÜniversitesiAmaç: Tiroidektomi sonrası geçici hipokalsemi en sık görülen komplikasyondur ve oluştuğunda kolaytedavi edilir. Geçici hipokalsemi ile ilişkili esas problem hastanede kalış süresini uzatmasıdır. Bu çalış -manın amacı tiroid cerrahisi uygulanan hasta grubunda postoperatif geçici hipokalsemi için risk fak -törlerini belirlemekti.Gereç ve Yöntem: Ocak 2012 - Aralık 2013 tarihleri arasında total tiroidektomi uygulanan 177 has -tanın verileri retrospektif olarak değerlendirildi. Hipokalsemi total serum kalsiyum düzeyinin 8 mg/dl altında olması olarak tanımlandı. Geçici hipokalsemi total tiroidektomiyi takiben 6 ayda hipokalse -minin iyileşmesi olarak tanımlandı. Geçici hipokalsemi için risk faktörleri olarak cinsiyet, preopera -tif D vitamini eksikliği, reküren hastalık için cerrahi girişim, hipertiroidi varlığı, görülen ve korunanparatiroid bez sayısı, paratiroid bez ekimi yapılması, patolojik spesmende çıkarılan paratiroid bezivarlığı değerlendirildi. İstatistik değerlendirmede Nominal Lojistik Regresyon analizi, Ki-kare testive Fisherin Kesinlik testi kullanıldı.Bulgular: Çalışmadaki 177 hastanın (150K, 27E) 37sinde (%20.9) geçici hipokalsemi gelişti. Nominalregresyon analizinde sadece patolojik spesmende çıkarılan paratiroid bezi varlığı (p=0.025) geçicihipokalsemi için bağımsız değişken faktör olarak belirlendi.Sonuç: Patolojik spesmende paratiroid bezi varlığı yüksek oranda geçici hipokalsemiden sorumludur.Tiroidektomi esnasında cerrahi spesmenin intraoperatif dikkatli incelenmesi uygunsuz paratiroidek -tomi insidansını azaltabilir.Publication Open Access Contribution of intraoperative neuromonitoring to the identification of the external branch of superior laryngeal nerve(2017) Uludağ, Mehmet; Aygün, Nurcihan; İşgör, Adnan; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Bahçeşehir ÜniversitesiObjective: We evaluated the contribution of intraoperative neuromonitoring to the visual and functional identification of the external branch of the superior laryngeal nerve.Material and Methods: The prospectively collected data of patients who underwent thyroid surgery with intraoperative neuromonitoring for external branch of the superior laryngeal nerve exploration were assessed retrospectively. The surface endotracheal tube-based Medtronic NIM3 intraoperative neuromonitoring device was used. The external branch of the superior laryngeal nerve function was evaluated by the cricothyroid muscle twitch. In addition, contribution of external branch of the superior laryngeal nerve to the vocal cord adduction was evaluated using electromyographic records.Results: The study included data of 126 (female, 103, male, 23) patients undergoing thyroid surgery, with a mean age of 46.2±,12.2 years (range, 18-75 years), and 215 neck sides were assessed. Two hundred and one (93.5%) of 215 external branch of the superior laryngeal nerves were identified, of which 60 (27.9%) were identified visually before being stimulated with a monopolar stimulator probe. Eighty-nine (41.4%) external branch of the superior laryngeal nerves were identified visually after being identified with a probe. Although 52 (24.1%) external branch of the superior laryngeal nerves were identified with a probe, they were not visualized. Intraoperative neuromonitoring provided a significant contribution to visual (p<,0.001) and functional (p<,0.001) identification of external branch of the superior laryngeal nerves. Additionally, positive electromyographic responses were recorded from 160 external branch of the superior laryngeal nerves (74.4%). Conclusion: Intraoperative neuromonitoring provides an important contribution to visual and functional identification of external branch of the superior laryngeal nerves. We believe that it can not be predicted whether the external branch of the superior laryngeal nerve is at risk or not and the nerve is often invisible, thus, intraoperative neuromonitoring may routinely be used in superior pole dissection. Glottic electromyography response obtained via external branch of the superior laryngeal nerve stimulation provides quantifiable information in addition to the simple visualization of the cricothyroid muscle twitch.Publication Metadata only Extralaryngeal division of the recurrent laryngeal nerve: A common and asymmetric anatomical variant(2017) Celayir, Fevzi; Oran Şen, Ebru; Yetkin, Sıtkı Gürkan; Uludağ, Mehmet; Aygün, Nurcihan; İşgör, Adnan; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Bahçeşehir ÜniversitesiObjective: Recognition of extralaryngeal branching of the recurrent laryngeal nerve is crucial because prevention of vocal cord paralysis requires preservation of all branches of the recurrent laryngeal nerve. We assessed the prevalence of extralaryngeal branching of the recurrent laryngeal nerve and the median branching distance from the point of bifurcation to the entry point of the nerve into the larynx.Material and Methods: Prospective operative data on recurrent laryngeal nerve branching were collected from 94 patients who underwent thyroid or parathyroid surgery between September 2011 and May 2012.Results: A total of 161 recurrent laryngeal nerves were examined (82 right, 79 left). Overall, 77 (47.8%) of 161 recurrent laryngeal nerves were bifurcated before entering the larynx. There were 36 (43.9%) branching nerves on the right and 41 (51.9%) branching nerves on the left, and there was no significant difference between the sides in terms of branching (p=0.471). Among 67 patients who underwent bilateral exploration, 28.4% were found to have bilateral branching, 40.3% had unilateral branching, and the remaining 31.3% had no branching. The median branching distance was 15 mm (5-60mm).Conclusion: Extralaryngeal division of recurrent laryngeal nerve is a common and asymmetric anatomical variant. These variations can be easily recognized if the recurrent laryngeal nerve is identified at the level of the inferior thyroid artery and then dissected totally to the entry point of the larynx. Inadvertent division of a branch may lead to vocal cord palsy postoperatively, even when the surgeon believes the integrity of the nerve has been preserved.Publication Open Access Tiroit cerrahisinde intraoperatif sinir monitorizasyonunun temel prensipleri ve standardizasyonu(2017) Uludağ, Mehmet; Kaya, Cemal; Aygün, Nurcihan; Tanal, Mert; İşgör, Adnan; Oba, Sibel; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; T.C. Sağlık Bakanlığı; Bahçeşehir Üniversitesi; T.C. Sağlık BakanlığıTiroit cerrahisinde intraoperatif sinir monitorizasyonunun temel prensipleri ve standardizasyonuTiroit cerrahisi sonrası oluşan sesle ilgili problemler sık ve en önemli komplikasyonlardandır. Cerrahi sonrası hastanın ses ve solunum problemlerini minimalize edebilmek için hem reküren laringeal sinirin (RLS) hem de süperior laringeal sinirin eksternal dalının (SLSE) korunması gerekir. İntraoperatif nöromonitorizasyon (İONM) sinirin gözle görülmesine ek olarak ameliyat sırasında sinirin motor fonksiyonlarının dinamik olarak değerlendirilmesi temeline dayanan bir yöntemdir. Tiroit cerrahisinde İONM 50 yıl önce kullanılmaya başlanmış ve yüzey elektrotlu endotrakeal tüp ile İONM, amaca uygunluk, basitlik, noninvazif olma ve güvenlilik gibi nedenlerle standart uygulanan yöntem haline gelmiş olup, günümüzde tiroit cerrahisinde bu yöntem kullanılmaktadır. Tiroit cerrahisinde RLS ve SLSE için İONM kullanımı giderek artmaktadır. İONM'nin uygun kullanımı için hem anestezist hem cerrah için deneyim ve standardizasyonu şarttır. Bu bağlamda hem cerrahların hem de anestezistler için öğrenme eğrisi yaklaşık 50-100 arası olgudur. İONM hem RLS hem SLSE'nin bulunmasında ve fonksiyonel olarak değerlendirilmesinde önemli katkı sağlar. RLS monitorizasyonu monitorizasyon probu ile aralıklı veya vagusa uygulanan prob yardımı ile sürekli olarak uygulanabilir. RLS monitorizasyonunun standardizasyonu, preoperatif laringoskopi ile vokal kord muayenesi (L1), RLS diseksiyonu öncesi aynı taraf vagustan uyarı alınması (V1), RLS'nin trakeaozefageal olukta ilk bulunduğu noktada uyarılması (R1), diseksiyon bittikten sonra RLS'nin ortaya konduğu en proksimal noktasından uyarılması (R2), cerrahi alanda kanama kontrolü tamamlandıktan sonra vagusun uyarılması (V2), postoperatif laringoskopi ile vokal kord muayenesini (L2) içerir. V2 postoperatif vokal kord fonksiyonunu öngörmede en uygun testtir. RLS aralıklı İONM'sinde sadece sinirin probla uyarıldığı an ve sinirin uyarıldığı nokta distalinin fonksiyonu hakkında bilgi verir. Sürekli İONM ise RLS'nin vagustan ayrılmadan önce boyunda vagusa uygulanan probla yapılan devamlı uyarı sayesinde cerraha tiroidi diseke ederken RLS fonksiyonunun sürekli takip edilmesini sağlar. SLSE monitorizasyonunda primer olarak ameliyat sahasında bulunan ve SLSE'nin motor siniri olduğu krikotiroid kasın kasılması değerlendirilir. İONM hem RLS hem SLSE'nin bulunmasında ve fonksiyonel olarak değerlendirilmesinde önemli katkı sağlaması ile birlikte tiroidektomiye birçok açıdan katkı sağlayan ve tiroidektominin standartlarını arttıran bir yöntemdirPublication Open Access Complication Risk in Secondary Thyroid Surgery Original Research(2018) Mihmanlı, Mehmet; Uludağ, Mehmet; Yetkin, Gürkan; Aygün, Nurcihan; Besler, Evren; İşgör, Adnan; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Tanımlanmamış Kurum; T.C. Sağlık Bakanlığı; Sağlık Bilimleri ÜniversitesiObjectives: Secondary thyroid surgery is rare, compared with primary thyroid surgery. However, secondary surgery has a greater risk of complications due to the formation of scar tissue as well as increased fragility of the tissues following the previous surgery. Several surgical techniques and strategies have been recommended to decrease the complication rate associated with secondary surgery. The aim of this study was to evaluate the complication rate in patients who underwent secondary thyroid surgery using a lateral approach and intraoperative nerve monitoring (IONM).Methods: The data of 44 patients who underwent secondary surgical intervention after thyroid surgery performed for benign or malignant thyroid disease (Group 1), and of 44 patients who underwent primary surgery (Group 2) were compared. Lobectomy patients with a histopathological result of malignant disease, whom were applied completion thyroidectomy were excluded from the study. Secondary surgery was performed using a lateral approach. Access was achieved between the anterior edge of the sternocleidomastoid muscle and the strap muscles. In primary surgery, the thyroid lodge was entered through the midline. Standard IONM was applied in all cases. Hypocalcemia was defined as a serum calcium level of <,=8 mg/dL within the first postoperative 48 hours, regardless of clinical symptoms. Transient and permanent recurrent laryngeal nerve paralysis was evaluated based on the number of nerves at risk. The lobectomy was considered to be high-risk with the presence of recurrence, Graves' disease, substernal goiter, and application of central dissection.Results: The mean age of Group 1 and 2 was 49.9±,14.1 years and 45±,12.6 years , respectively (range: 22-90 years, p=0.69). Female patients constituted 90.9% (n=40) of the population in Group 1 and 75% (n=33) of the patient population in Group 2 (p=0.87). In Group 1, 11 (25%) patients, and 7 (15.9%) patients in Group 2 underwent surgical intervention due to the presence of a malignant disease (p=0.29). Bilateral intervention was applied in 26 (59.1%) patients in Group 1 and 28 (63.6%) patients in Group 2. The rate of transient and permanent hypocalcemia in Groups 1 and 2 was 34.1% (n=15) vs 22.5%, and 2.5% (n=1) vs 0%, respectively, without any significant intergroup difference (p=0.237, p=1). In Group 1, 71 lobes were operated on, and there were 72 in Group 2. All of the interventions in Group 1 (100%), and 31.9% (n=23) of those in Group 2 were high-risk, and there was a significant intergroup difference (p<,0.0001). The rate of transient and permanent vocal cord paralysis were 4.2% (n=3) vs 2.8% (n=2) and 6.9 % (n=5) vs 0% in Groups 1 and 2, respectively (p=0.719, p=0.245).Conclusion: When performed with a meticulous and attentive technique, secondary surgical intervention can be applied without increasing the incidence of permanent complications. Though there is substantial risk associated with all of these procedures, the rate of vocal cord paralysis was similar to that seen after primary intervention, and was thought to be related to surgical experience and technique, as well as the use of IONM.Publication Open Access Can Active Surveillance be an Alternative to Surgery in Papillary Thyroid Microcarcinoma?: The Current Situation Worldwide(2018) Aygün, Nurcihan; İşgör, Adnan; Uludağ, Mehmet Emin; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiPapillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumorswith a size of ≤1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosisof PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension tothe tracheal or recurrent laryngeal nerve invasion, is poor, even if a sufficient immediate surgery is performed at diagnosis. However,PTMCs without these aggressive features are low-risk tumors because of their indolent and slow growth behaviors. The increasein thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despitethe sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatmentstrategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate,and potential risk for postoperative complications, active surveillance has been proposed recently as an alternative option forPTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillanceof low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression,and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting towardmore conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to activesurveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidenceextended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediatesurgery for appropriately selected patients with PTMC.
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