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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 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 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 Open Access Scarless Thyroidectomy: Transoral Endoscopic Thyroidectomy by Vestibular Approach(2017) Uludağ, Mehmet; İşgör, Adnan; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesiİzsiz tiroidektomi: Vestibüler yaklaşımla transoral endoskopik tiroidektomi Vestibüler yaklaşımla transoral endoskopik tiroidektomi (TOETVA) minimal invaziv, görünür yara izi olmayan naturel orifis transluminal endoskopik cerrahi (Naturel orifice transluminal endoscopic surgery (NOTES) tekniktir. Ağız içinden vestibüler bölgeden uygulanan 1 adet 10 mm ve 2 adet 5 mm port yardımı ile düşük CO2 basıncı altında tamamen endoskopik olarak lobektomi veya total tiroidektomi uygulanabilir. Dünyada giderek uygulaması artmaktadır. Deneyimli merkezlerde seçilmiş hastalarda güvenli bir şekilde uygulabilmektedir. Bu çalışmada minimal invaziv tiroit cerrahisinin gelişimi, TOETVA için hasta seçimi ve dışlama kriterleri, bölgesel anatomi, ameliyat tekniği, preoperatif ve postoperatif bakım, yöntemin avantajları, dezavantajları ve olası komplikasyonları tartışılacaktır.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 Surgical approaches for papillary microcarcinomas: Turkey’s perspective(2018) Makay, Özer; Tezelman, Serdar; Özcan, Zehra; Şenyürek, Yasemin Giles; Uludağ, Mehmet; İşgör, Adnan; Özbaş, Serdar; Özdemir, Murat; İçöz, Recep Gökhan; Tunca, Fatih; Düren, Mete; Tanımlanmamış Kurum; Koç Üniversitesi; Ege Üniversitesi; İstanbul Üniversitesi; T.C. Sağlık Bakanlığı; Bahçeşehir Üniversitesi; Tanımlanmamış Kurum; Tanımlanmamış Kurum; Tanımlanmamış Kurum; İstanbul Üniversitesi; İstanbul ÜniversitesiObjectives: The incidence of papillary microcarcinomas, which are defined as thyroid cancers of <10mm in size,has been increasing in the last decade. Herein, we present internet-based questionnaire results performed by theTurkish Association of Endocrine Surgery with the aim to evaluate the perspective of the management of papillarymicrocarcinomas in Turkey.Material and Methods: The user-friendly questionnaire consisted of 13 questions in total. These questions mainlyaddressed the surgical management of nodules and cancer of <1 cm in size. Patient management before, during,and after surgical intervention was also included, additionally, the “active surveillance approach” was questioned.Results: There were 420 responders in total who were of multidisciplinary origin (endocrinologists, surgeons, nuclearmedicine specialists, pathologists, and oncologists). Total thyroidectomy was the predominant treatment approach(65%) for the classical type of microcarcinoma limited in one lobe, whereas in cases of microcarcinomasincidentally diagnosed during hemithyroidectomy, complementary surgery approach was advised by 40% of theresponders. The responders found capsule invasion (86%) and patient based management (94%) of high importance.The percentage of the responders who recommended radioactive iodine ablation in incidental cancers having noaggressive criteria was 51%. The survey participants that were against routine central dissection in these cases accountedfor 73% of the responders. The recommendation of active surveillance (follow-up without any interventionaltherapy) was limited with 9% responders.Conclusion: The results of the questionnaire demonstrated that there have been various choices in Turkey for thesurgical treatment of the papillary microcarcinomas.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.Publication Open Access Main Surgical Principles and Methods in Surgical Treatment of Primary Hyperparathyroidism(2019) Uludağ, Mehmet; Aygün, Nurcihan; İşgör, Adnan; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir ÜniversitesiThe 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 anatomyand embryology. The lower parathyroid glands develop from the dorsal portion of the third pharyngeal pouch, and the upperparathyroid glands from the fourth pharyngeal pouch. Humans typically have 4 parathyroid glands, however, more than 4 andfewer than 4 have been observed. Typically, the upper parathyroid glands are located in the cricothyroid junction area on theposterolateral portion of the middle and upper third of the thyroid, while the lower parathyroids are located in an area 1 cm indiameter located posterior, lateral, or anterolateral to the lower thyroid pole. Ectopic locations of parathyroid glands outside thenormal 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 roboticparathyroidectomy methods performed from remote regions outside the neck have been reported. Although currently MIP is thestandard treatment option in selected patients with positive imaging, BNE remains the gold standard procedure in parathyroidsurgery. 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 positiveresults. The parathyroid surgeon must also know the BNE technique and be able to switch to BNE and change the surgical strategyif necessary. If the intended gland is not found in its normal anatomical site, possible embryological and acquired ectopic locationsshould be investigated. It should be kept in mind that MIP and BNE are not alternatives to each other, but rather complementarytechniques for successful treatment in parathyroid surgery.Publication Open Access The Effectiveness of Preoperative Ultrasonography and Scintigraphy in the Pathological Gland Localization in Primary Hyperparathyroidism Patients(2019) Uludağ, Mehmet; Aygün, Nurcihan; İşgör, Adnan; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir ÜniversitesiObjectives: Primary hyperparathyroidism (pHPT) is a common disease, and its curative treatment is surgical. Nowadays, preoperative localization studies have become standard before surgical treatment, and the first stage imaging methods are ultrasonography and/or scintigraphy. With the contribution of these studies to the localization of the pathological gland, focused surgery hasbecome the first standard of choice. In this study, we aimed to evaluate the efficacy of ultrasonography and scintigraphy in thepreoperative localization of the pathologic gland or glands in patients who underwent surgical treatment and cure for pHPT.Methods: In this study, the data of the biochemically diagnosed pHPT patients, who had Tc 99m-MIBI scintigraphy and/or ultrasonography for localisation preoperatively, were evaluated retrospectively. The lesion, which was positive in USG or scintigraphyfor localization, was evaluated according to the neck side or neck quadrant, and the results were compared with intraoperativelocalization findings. The effectiveness of both methods and combinations was evaluated with the localization rates, sensitivityand positive predictive values (PPV). The three methods were compared with the Youden index (J).Results: The mean age of 380 patients included in this study was 54.8±12.8 years (20-83). Three hundred eight of them werefemale, and 72 were male. Scintigraphy was performed in 339 patients, USG was performed in 344 patients, and both USG andscintigraphy were performed in 306 patients. One hundred twenty patients (32%) underwent bilateral neck exploration (BNE), and260 patients (68.4%) underwent minimally invasive parathyroidectomy (MIP) (unilateral exploration or focused surgery). Singleadenoma was detected in 358 (94%), double adenoma in 10 (3%) and hyperplasia in 12 (3%) patients.Localization rates of USG, scintigraphy, USG and scintigraphy combinations were 53%, 74%, 75%, their sensitivity was 56%, 85%,89%, PPDs were 90%, 86%, 83%. The efficiency of scintigraphy is higher than USG (J: 0.743 vs 0.527). The contribution of scintigraphy to USG in combination with USG was limited (J: 0.743 vs 0.754).The localization rates of USG, scintigraphy, USG and scintigraphy combinations were 46%, 64%, 66%, their sensitivity was 51%,83%, 88%, PPDs were 79%, 74%, 73%. The efficiency of scintigraphy is higher than that of USG (J: 0.64 vs 0.427). The contribution ofscintigraphy to USG in combination with USG was limited (J: 0.64 vs 0.66).Conclusion: In patients with pHPT, scintigraphy is a more effective method for USG as the first step preoperative imaging andshould be preferred as the first method if there is no contraindication. A combination of scintigraphy with USG may contributeminimally to the efficacy of scintigraphy. It may be advantageous for early detection of the pathologic gland in patients with incompatible two imaging and initiating surgery on the positive side of the first scintigraphy. Scintigraphy and USG methods mayallow successful MRP surgery in the majority of patients with pHPT.