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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 Complication Risk in Secondary Thyroid Surgery(YERKURE TANITIM YAYINCILIK HIZMETLERI AS, 2018) Aygun, Nurcihan; Besler, Evren; Yetkin, Gurkan; Mihmanli, Mehmet; Isgor, Adnan; Uludag, Mehmet; University of Health Sciences Turkey; Bahcesehir UniversityPublication Metadata only Endocrine Surgery during the COVID-19 Pandemic: Recommendations from the Turkish Association of Endocrine Surgery(KARE PUBL, 2020) Aygun, Nurcihan; Iscan, Yalin; Ozdemir, Murat; Soylu, Selen; Aydin, Oguz Ugur; Sormaz, Ismail Cem; Dural, Ahmet Cem; Sahbaz, Nuri Alper; Teksoz, Serkan; Makay, Ozer; Emre, Ali Ugur; Haciyanli, Mehmet; Icoz, Recep Gokhan; Giles, Yasemin; Isgor, Adnan; Uludag, Mehmet; Tunca, Fatih; University of Health Sciences Turkey; Istanbul University; Ege University; Guven Hastanesi; University of Health Sciences Turkey; Istanbul University - Cerrahpasa; Bahcesehir University; Memorial Healthcare GroupThe 2019 novel coronavirus disease (COVID-19) was initially seen in Wuhan, China, in December 2019. World Health Organization classified COVID-19 as a pandemic after its rapid spread worldwide in a few months. With the pandemic, all elective surgeries and non-emergency procedures have been postponed in our country, as in others. Most of the endocrine operations can be postponed for a certain period. However, it must be kept in mind that these patients also need surgical treatment, and the delay time should not cause a negative effect on the surgical outcome or disease process. It has recently been suggested that elective surgical interventions can be described as medically necessary, time-sensitive (MeNTS) procedures. Some guidelines have been published on proper and safe surgery for both the healthcare providers and the patients after the immediate onset of the COVID-19 pandemic. We should know that these guidelines and recommendations are not meant to constitute a position statement, the standard of care, or evidence-based/best practice. However, these are mostly the opinions of a selected group of surgeons. Generally, only life-threatening emergency operations should be performed in the stage where the epidemic exceeds the capacity of the hospitals (first stage), cancer and transplantation surgery should be initiated when the outbreak begins to be controlled (second stage), and surgery for elective cases should be performed in a controlled manner with suppression of the outbreak (third stage). In this rapidly developing pandemic period, the plans and recommendations to be made on this subject are based on expert opinions by considering factors, such as the course and biology of the disease, rather than being evidence-based. In the recent reports of many endocrine surgery associations and in various reviews, it has been stated that most of the cases can be postponed to the third stage of the epidemic. We aimed to evaluate the risk reduction strategies and recommendations that can help plan the surgery, prepare for surgery, protect both patients and healthcare workers during the operation and care for the patients in the postoperative period in endocrine surgery.Publication Metadata only Recent Developments of Intraoperative Neuromonitoring in Thyroidectomy(KARE PUBL, 2021) Aygun, Nurcihan; Kostek, Mehmet; Isgor, Adnan; Uludag, Mehmet; University of Health Sciences Turkey; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir University; Memorial Healthcare GroupAt present, intraoperative neuromonitorization (IONM) with surface electrode-based endotracheal tube (ETT) is a standard method in thyroidectomy and can be performed either intermittently IONM (I-IONM) or continuously IONM (C-IONM). Despite the valuable contribution of I-IONM to the thyroidectomy, it still has limitations regarding the recording electrodes and stimulation probe. New approaches for overcoming the limitations of I-IONMand developing the method are taking attention. Most of the technical issues of IONM with surface electrode-based ETT are related with inadequate contact of electrodes to the vocal cords. Nowadays, efficiency of various recording electrodes is under investigation. Recording electrodes such as needle electrodes applied to thyroarytenoid or posterior cricoarytenoid muscle (PCA), surface electrodes applied to the PCA, and needle or adhesive electrodes applied to the tracheal cartilage or skin, can make safe recordings similar to the ETT electrodes. Despite their invasiveness, needle electrodes record higher electromyography (EMG) amplitudes than tube electrodes do. Adhesive surface electrodes make safe EMG recordings, although hamplitudes of these electrodes are usually lower than those of the tube electrodes. These different types of electrodes are less affected by tracheal manipulations and amplitude changes are lower compared to the tube electrodes. During C-IONM, an additional stimulation probe is applied to the vagus nerve after dissecting the nerve circumferentially. Recently, without applying a probe, a new continuous monitorization method called laryngeal adductor reflex CIONM (LAR-CIONM) using sensorial, central, and motor components of LAR arch which is an automatic, primitive brainstem reflex protecting the tracheoesophageal tree from foreign body aspiration, has been implemented. Afferent track of LAR communicates laryngeal mucosa to the brainstem by internal branch of the superior laryngeal nerve and efferent track reaches larynx through recurrent laryngeal nerve. Total outcome of LAR activation is the closure of laryngeal entry by bilateral vocal cord adduction. In LAR-CIONM, a stimulus is given by an electrode from one side of surface electrode-based ETT and amplitude response of the LAR at the vocal cord is followed on the operation side. Recently, it has been reported that real-time EMG response can be obtained with stimulation probe cables applied to dissectors or energy devices during the dissection throughI-IONM.Publication Metadata only Surgical approaches for papillary microcarcinomas: Turkey's perspective(AVES, 2018) Makay, Ozer; Ozdemir, Murat; Senyurek, Yasemin Giles; Tunca, Fatih; Duren, Mete; Uludag, Mehmet; Haciyanli, Mehmet; Icoz, Gokhan; Isgor, Adnan; Ozbas, Serdar; Ozcan, Zehra; Tezelman, Serdar; Ege University; Ege University; Istanbul University; Istanbul University - Cerrahpasa; Istanbul University; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Izmir Katip Celebi University; Bahcesehir University; Guven Hastanesi; Koc UniversityObjectives: 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 the Turkish Association of Endocrine Surgery with the aim to evaluate the perspective of the management of papillary microcarcinomas in Turkey. Material and Methods: The user-friendly questionnaire consisted of 13 questions in total. These questions mainly addressed 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, nuclear medicine 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 microcarcinomas incidentally diagnosed during hemithyroidectomy, complementary surgery approach was advised by 40% of the responders. 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 no aggressive criteria was 51%. The survey participants that were against routine central dissection in these cases accounted for 73% of the responders. The recommendation of active surveillance (follow-up without any interventional therapy) was limited with 9% responders. Conclusion: The results of the questionnaire demonstrated that there have been various choices in Turkey for the surgical treatment of the papillary microcarcinomas.Publication Metadata only Effects of Central Neck Dissection on Complications in Differentiated Thyroid Cancer(KARE PUBL, 2021) Unlu, Mehmet Taner; Aygun, Nurcihan; Demircioglu, Zeynep Gul; Isgor, Adnan; Uludag, Mehmet; University of Health Sciences Turkey; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Kars State Hospital; Bahcesehir UniversityObjective: It is still controversial whether performing central neck dissection (CND) in addition to total thyroidectomy ( TT) increases the risk of complications. In the present study, we aimed to evaluate the effect of CND on the development of complications in differentiated thyroid cancer (DTC) compared to TT. Material and Methods: The data of 186 patients (136 females and 50 males) with a mean age of 48.73 +/- 14.78 (range, 17-82) whom were operated for DTC were evaluated retrospectively. The patients were divided into two groups, TT (Group 1) and CND +/- TT/ Completion thyroidectomy +/- lateral neck dissection (Group 2). Results: There were 117 (91 F, 26 M) patients in Group 1 and 69 (45 F, 24 M) patients in Group 2. Parathyroid auto transplantation (PA) was significantly higher in Group 2 compared to Group 1 (42% vs. 6%) (p=0.000). Total (58% vs. 21.4%, respectively, p=0.000) and transient hypoparathyroidism (52.2% vs. 20.5%, respectively, p=0.000) were significantly higher in Group 2 than in Group 1, but permanent hypoparathyroidism rates were statistically not significant (5.8% vs. 0.9%, respectively, p=0.064). In the multinomial logistic regression analysis, CND alone was determined as an independent risk factor for increased both total and transient hypoparathyroidism. The relative risk (RR) of CND for total hypoparathyroidism was 5.2 times increased (odds ratio [OR]: 0.192) (p=0.007), while the RR for transient hypoparathyroidism was 3.5 times increased (OR: 0.285) (p=0.036). According to the number of nerves at risk, CND was performed in 119 neck side and only thyroidectomy was performed in 253 neck side. Total vocal cord paralysis (VCP) rate (9 [7.6%] vs. 6 [2.4%], respectively) (p=0.017) and transient VCP rate (7 [6%] vs. 4 [1.6%], respectively) (p=0.021) in patients who underwent CND were significantly higher compared to those who underwent only thyroidectomy. In multinomial logistic regression analysis performing only CND was an independent risk factor for total VCP, and increased the total VCP RR approximately 5.34 times (OR:0.184, p=0.007). Conclusion: Although CND can be applied without increasing the rates of permanent hypoparathyroidism and VCP compared to TT, it increases the risk of total and transient hypoparathyroidism, total, and transient VCP. Patients undergoing CND should be followed carefully in terms of transient hypoparathyroidism.Publication Metadata only Influence of Recurrent Laryngeal Nerve Variations on Vocal Cord Paralysis(ERCIYES UNIV SCH MEDICINE, 2022) Aygun, Nurcihan; Demircioglu, Mahmut Kaan; Demircioglu, Zeynep Gul; Unlu, Mehmet Taner; Akgun, Ismail Ethem; Isgor, Adnan; Uludag, Mehmet; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Kars State Hospital; Bahcesehir UniversityObjective: Vocal cord paralysis (VCP) due to recurrent laryngeal nerve (RLN) injury is a significant potential complication of thyroid and parathyroid surgery. The aim of this study was to investigate the influence on VCP of the anatomical relationship of the RLN to the inferior thyroid artery (ITA) and extralaryngeal branching of the RLN. Materials and Methods: The data of 123 patients (95 female, 28 male, mean age: 46+13.6 years), a total of 204 neck sides, who underwent a thyroidectomy and/or a parathyroidectomy performed with intraoperative nerve monitoring between March and December 2015 were evaluated retrospectively. Preoperative and postoperative vocal cord examinations were performed in all cases. RLN branching at a distance of >5 mm with both branches entering the larynx was considered extralaryngeal branching of the nerve. Age, gender, nerve side, RLN branching, and the relationship between the RLN and the ITA were evaluated to assess the possible effect on VCP. Results: Of the 204 neck sides, 11 (5.4%) RLNs developed VCP. Ten cases were temporary (4.9%) and 1 (0.5%) was permanent. There was no significant difference in age, gender, nerve side, or RLN-ITA relationship in the VCP cases. Extralaryngeal branching was detected in 42 (22.7%) of 185 nerves, and the rate of total and transient VCP was significantly higher in branching nerves than in nonbranching nerves (11.9% vs 3.5%, p=0.034, 11.9% vs 2.8%, p=0.030, respectively). Conclusion: RLN branching is a potential risk factor for total and transient VCP, awareness of this anatomical variation and complete exposure during thyroid surgery are crucial to the prevention of RLN iniury.Publication Metadata only Parathyroidectomy Results in Primary Hyperparathyroidism: Analysis of the Results From a Single Center(KARE PUBL, 2021) Unlu, Mehmet Taner; Aygun, Nurcihan; Akgun, Ismail Ethem; Yetkin, Sitki Gurkan; Erol, Rumeysa Selvinaz; Isgor, Adnan; Uludag, Mehmet; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir UniversityObjectives: The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may develop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery for PHPT in our clinic. Methods: The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and 2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidectomy were included in the study. Surgical cure and persistent and recurrent disease rates were evaluated in patients. Results: During this period, 368 interventions were performed in 357 patients (293 F and 64 M) who were operated for PHPT in our clinic, with a mean age of 54.9 +/- 13.1 years. In the first surgery, 116 patients (32.5%) had bilateral neck exploration, 251 patients (67.5%) had unilateral neck exploration (UNE) or focused parathyroid surgery (FPS). In the first operation, 343 patients (96.1%) had cure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS was performed to 10 patients (90.9%), partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these patients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Four patients remained persistent (1.1%). Recurrent disease developed in four patients during follow-up (1.1%). Total cure rate was 97.8%. Conclusion: The only definitive treatment for PHPT is surgery. High surgical cure can be achieved by pre-operative evaluation and appropriate surgical planning. However, persistent PHPT may develop, especially due to double adenoma or ectopic location. Patients with persistent PHPT can be evaluated with repeat imaging methods and with appropriate surgical planning, a high cure rate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.Publication 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.