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Publication Metadata only A Review of Methods for the Preservation of Laryngeal Nerves During Thyroidectomy(KARE PUBL, 2018) Uludag, Mehmet; Tanal, Mert; Isgor, Adnan; University of Health Sciences Turkey; Bahcesehir University; Memorial Healthcare GroupPublication Metadata only Standards and Definitions in Neck Dissections of Differentiated Thyroid Cancer(YERKURE TANITIM YAYINCILIK HIZMETLERI AS, 2018) Uludag, Mehmet; Tanal, Mert; Isgor, Adnan; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir University; Memorial Healthcare GroupPublication Metadata only Can Active Surveillance be an Alternative to Surgery in Papillary Thyroid Microcarcinoma?: The Current Situation Worldwide(KARE PUBL, 2018) Aygun, Nurcihan; Isgor, Adnan; Uludag, Mehmet; University of Health Sciences Turkey; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir University; Memorial Healthcare GroupPapillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumors with a size of <= 1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosis of PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension to the 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 increase in thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despite the sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatment strategy 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 for PTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillance of 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 toward more conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to active surveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidence extended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediate surgery for appropriately selected patients with PTMC.Publication Metadata only Main Surgical Principles and Methods in Surgical Treatment of Primary Hyperparathyroidism(KARE PUBL, 2019) Uludag, Mehmet; Aygun, Nurcihan; Isgor, Adnan; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; University of Health Sciences Turkey; Bahcesehir UniversityThe only curative treatment for primary hyperparathyroidism (pHPT) is surgery. The most important factors that increase the success rate of a parathyroidectomy are the establishment of the correct diagnosis and the surgeon's good knowledge of anatomy and embryology. The lower parathyroid glands develop from the dorsal portion of the third pharyngeal pouch, and the upper parathyroid glands from the fourth pharyngeal pouch. Humans typically have 4 parathyroid glands, however, more than 4 and fewer than 4 have been observed. Typically, the upper parathyroid glands are located in the cricothyroid junction area on the posterolateral portion of the middle and upper third of the thyroid, while the lower parathyroids are located in an area 1 cm in diameter located posterior, lateral, or anterolateral to the lower thyroid pole. Ectopic locations of parathyroid glands outside the normal anatomical regions due to the abnormal migration during embryological development or acquired ectopy due to migration of enlarged parathyroids are not uncommon. There are various surgical techniques to treat HPT, however, 2 main surgical options are used: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP). While there are open, endoscopic, and video-assisted MIP (MIVAP) approaches, most often an open lateral MIP technique is used. In addition, endoscopic or robotic parathyroidectomy methods performed from remote regions outside the neck have been reported. Although currently MIP is the standard treatment option in selected patients with positive imaging, BNE remains the gold standard procedure in parathyroid surgery. In 80% to 90% of patients with pHPT, a pathological parathyroid gland can be detected with preoperative imaging methods and MIP can be applied. However, the pathological gland may not be found during a MIP procedure as a result of false positive results. The parathyroid surgeon must also know the BNE technique and be able to switch to BNE and change the surgical strategy if necessary. If the intended gland is not found in its normal anatomical site, possible embryological and acquired ectopic locations should be investigated. It should be kept in mind that MIP and BNE are not alternatives to each other, but rather complementary techniques for successful treatment in parathyroid surgery.Publication Metadata only Basic Principles and Standardization of Intraoperative Nerve Monitoring in Thyroid Surgery(KARE PUBL, 2017) Uludag, Mehmet; Aygun, Nurcihan; Kaya, Cemal; Tanal, Mert; Oba, Sibel; Isgor, Adnan; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Siverek State Hospital; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir UniversityVoice changes after thyroid surgery are frequent and one of the most important complications. Both the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN) must be preserved to minimize the patient's voice and respiratory problems after surgery. Intraoperative neuromonitoring (IONM) is a method based on dynamically evaluating motor function of the nerve during surgery in addition to the visual identification of the nerve. Intraoperative neuromonitoring was introduced 50 years ago in thyroid surgery and IONM via endotracheal tube with surface electrodes has become a standard applied method for reasons such as convenience, simplicity, non-invasiveness and safety, and nowadays is used in thyroid surgery. The use of IONM for RLN and EBSLN is increasing in thyroid surgery. Experience and standardization is essential for proper use of IONM for both anesthesiologist and surgeon. In this context, the learning curve for both surgeons and anesthetists is about 50-100 cases. Intraoperative neuromonitoring makes a significant contribution to the identification and functional evaluation of both RLN and EBSLN. RLN monitorisation can be performed intermittently with the monitoring probe or continuously with the aid of a probe applied to the vagus. Standardization of RLN monitoring includes the vocal cord examination via preoperative laryngoscopy (L1), getting signals from ipsilateral vagus prior to RLN dissection (V1), stimulation of RLN at the first point found in the tracheoesophageal groove (R1), stimulation of the RLN from the most proximal point it was revealed after the dissection was completed (R2), vagus stimulation after surgical site bleeding control is complete (V2), vocal cord examination via postoperative laryngoscopy (L2). V2 is the most appropriate test to predict postoperative vocal cord function. In the intermittent IONM of RLN, only the nerve stimulated by the probe and the point that the nerve is stimulated inform about the function of the distal part. Continuous IONM allows continuous follow-up of RLN function while dissecting the thyroid gland by continuous stimulation of the RLN with the probe applied to the vagus at the neck before RLN leaves the vagus. Primarily in EBSLN monitoring, the contraction of the cricothyroid muscle, which is located in the surgical field and whose motor neuron is EBSLN, is evaluated. Intraoperative neuromonitoring is a method that contributes to many aspects of thyroidectomy and increases the standards of thyroidectomy, together with significant contribution to the detection and functional evaluation of both RLN and EBSLN.Publication Metadata only What has changed about the eight edition of the differentiated thyroid carcinomas TNM classification system? How will it effect the clinical practice?(KARE PUBL, 2017) Uludag, Mehmet; Isgor, Adnan; University of Health Sciences Turkey; Bahcesehir UniversityThe eighth edition of the TNM classification system was announced. Thyroid cancers were included in the fourth edition of the TNM classification system which was published in 1987. Each version of the TNM system which is updated based on evidence in the literature, includes some important differences from the previous version for the differentiated thyroid carcinomas (DTCs), like other cancers. Seventeen different classification systems for thyroid cancer have been developed until today. Some of these systems are quite complex and are difficult to use in practice. It has been shown that the TNM system with the new regaulations is the most consistent and applicable staging system for DTC in different patient groups, and the TNM system is now the most commonly used classification system in thyroid cancer, as in other cancer types. The most important update of the eighth version is that the age as prognostic factor is regulated as younger and older than 55 years, which has been divided as younger/older than 45 years of age in prior editions. Furthermore, the change in the definition of T3 in the T stage is remarkable. In the seventh edition, the definition of minimally invasive extrathyroidal extension and the definition of perithyroidal soft tissue included in its example have been abolished. Macroscopic extension into any of the strap muscles was moved to the T3 category in the eighth edition. In N staging in the 7th edition, the upper mediastinal lymph node involvement which took place in N1b was moved to the N1a category. In the eighth edition, it is observed that generally in patients over 55 years old have a stage downgrade in all stages compared to the seventh edition. In the eighth edition, the appropriate tumor stage can easily be determined. In patients under the age of 55 years, patients with distant metastases were defined as stage II, and without as stage I. Patients with distant metastasis over the age of 55 years are defined as stage IVB. The stages of patients without distant metastases over the age of 55 years can be defined by other clinical features (intrathyroidal tumor, macroscopic extrathyroidal extension, lymph node metastasis and distant metastasis). If there is no lymph node metastasis in patients with intrathyroidal tumors smaller than 4 cm (T1, T2), it is called stage 1, and stage II, if lymph node metastasis is present. Patients with intrathyroidal tumors greater than 4 cm (T3) are placed in stage II, regardless of lymph node status (N0 or N1). In tumors with macroscopic extrathyroidal extension, irrespective of the lymph node metastasis, the tumor is in stage II if only invasive into the strap muscles, and stage III if extended to subcutaneous tissue, larynx, trachea, recurrent laryngeal nerve and esophagus, and stage IVA if extended to the prevertebral fascia, mediastinal vessels or if surrounded carotid artery. TNM classification is a staging system that reliably predicts disease-specific survival in the DTC. The eighth edition of TNM compared to the previous editions classifies a large proportion of patients with DTC in low-risk groups in terms of mortality, and initial evaluations show that it may be more suitable in predicting disease-specific survival.Publication Metadata only Scarless thyroidectomy: transoral endoscopic thyroidectomy by vestibular approach(KARE PUBL, 2017) Uludag, Mehmet; Isgor, Adnan; University of Health Sciences Turkey; Bahcesehir UniversityTransoral endoscopic thyroidectomy by vestibular approach (TOETVA) is a minimally invasive, natural orifice transluminal endoscopic surgery (NOTES) technique with no visible scarring. Endoscopic lobectomy or total thyroidectomy can be performed completely under low CO2 pressure level with the aid of one 10 mm and two 5 mm ports applied from vestibular region through the mouth. Its application is increasing worldwide. It can be safely performed in selected patients in experienced centers. In this study, the development of minimally invasive thyroid surgery, patient selection and exclusion criteria for TOETVA, regional anatomy, surgical technique, preoperative and postoperative care, advantages and disadvantages and possible complications of the procedure will be discussed.