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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 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 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 Anatomical, Functional, and Dynamic Evidences Obtained by Intraoperative Neuromonitoring Improving the Standards of Thyroidectomy(KARE PUBL, 2021) Aygun, Nurcihan; Kostek, Mehmet; Isgor, Adnan; Uludag, Mehmet; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir University; Memorial Healthcare GroupThe use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage of IONM regarding the laryngeal nerves' anatomy and function have provided important contributions for improving the standards of the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrent laryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations of RLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquired regarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innervation of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and gives motor branches both to the abductor and adductor muscles. In addition, up to 18% of posterior branches may have adductor and/ or abductor motor fibers. In 70-80% of cases, external branch of superior laryngeal nerve (EBSLN) provides motor innervation to the anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicating nerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid muscle which is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to the motor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is the most common reason of RLN injuries and constitutes of 67-93% of cases. More than 50% of EBSLN injuries are caused by nerve transection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the loss of signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cord paralysis ( VCP) develops in 70-80% of cases when LOS persists or incomplete recovery of signal occurs after waiting for 20 min. In case of complete recovery of signal, VCP is not expected. VCP is temporary in patients with incomplete recovery of signal and permanent VCP is not anticipated. Visual changes may be seen in only 15% of RLN injuries, on the other hand, IONM detects 100% of RLN injuries. IONM can prevent bilateral VCP. Continuous IONM (C-IONM) is a method in which functional integrity of vagus-RLN axis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makes significant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerve injury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.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 Non-Toxic Multinodular Goiter: From Etiopathogenesis to Treatment(KARE PUBL, 2022) Unlu, Mehmet Taner; Kostek, Mehmet; Aygun, Nurcihan; Isgor, Adnan; Uludag, Mehmet; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir University; Memorial Healthcare GroupGoiter term is generally used for defining the enlargement of thyroid gland. Thyroid nodules are very common and some of these nodules may harbor malignancy. Multinodular goiter (MNG) disease without thyroid dysfunction is defined as non-toxic MNG. There are many factors in etiology for development of MNG. They can be classified as iodine dependent and non-iodine dependent factors basically. Beyond this basic classification, the effect of many environmental and acquired factors is also effective on the development of goiter. Many methods have described for diagnosis and treatment for non-toxic MNG. Biochemical tests, imagining methods, invasive and non-invasive methods have been used for diagnosis for many years. Each method has advantages and disadvantages, separately. Although the best method for diagnosis is still debatable, distinguishing malignant nodules from benign nodules is the first and most important step for MNG. Biochemical tests such as serum thyroid stimulating hormone (TSH) measurement, thyroid hormone measurement, and thyroid ultrasonography are used for diagnosis of MNG, traditionally. Nowadays, there are some new techniques were developed like ultrasound-elastography. Furthermore, thyroid scintigraphy may be used if there is abnormal TSH measurement. Fine-needle aspiration biopsy and some cross-sectional imaging methods (computed tomography, magnetic resonance imaging, and positron emission tomography) could be used, too. After a certain diagnosis is made, treatment options should be evaluated. Many treatment methods have been used for goiter from ancient times upon today. From non-invasive methods such as medical follow-up to invasive methods such as lobectomy or thyroidectomy are options for treatment. Patients with compression symptoms due to an enlarged thyroid gland are usually candidates for surgery. In this study, it is aimed to determine the most appropriate treatment for the patient by discussing the advantages and disadvantages of all these methods. The present review discusses definition of goiter term, etiology, epidemiology, pathogenesis, diagnostic methods, and treatment methods for nontoxic MNG.Publication Metadata only Substernal Goiter: From Definitions to Treatment(KARE PUBL, 2022) Unlu, Mehmet Taner; Aygun, Nurcihan; Kostek, Mehmet; Isgor, Adnan; Uludag, Mehmet; Istanbul Sisli Hamidiye Etfal Training & Research Hospital; Bahcesehir UniversityThe enlargement of multinodular goiter into the mediastinum through the thoracic inlet or ectopic thyroid tissues directly in the mediastinum is defined as Substernal Goiter (SG). However, there is no clear consensus in the literature on this definition. There are many definitions for SG in the literature. Most definitions are similar or overlapping. Since the thyroid is located in the neck above the thoracic inlet in its normal anatomical position, the simplest clinical definition should be preferred among the definitions regarding its descent below the thoracic inlet and adjacent to the mediastinal organs. In the American Thyroid Association guideline, SG is defined as clinical or radiological protrusion of the thyroid gland over the sternal notch or clavicle in a patient with a slightly extended neck in the supine position. SGs can be classified as primary or secondary according to their origins. In addition, there are combined SGs resulting from the enlargement of the primary SG, which is the growth of the cervical thyroid gland toward the mediastinum, and the secondary SG, which is defined as an ectopic mediastinal mass, together. We find it appropriate to define such SGs as mixed SGs. In this disease, which has the same etiology and etiopathogenesis as cervical goiter, the descent of the thyroid gland into the mediastinum due to some anatomical factors explains the physiopathology. Compression symptoms of mediastinal major vascular structures, trachea, and esophagus cause the symptoms and findings of SGs due to its localization. In addition, the relationship of SGs with possible malignancy risk and hyperthyroidism affecting the indications and methods of treatment has been discussed for a long time. In this study, we aimed to evaluate the definitions, classification, physiopathology, laboratory and imaging methods used for diagnosis, the relationship of SG with hyperthyroidism and malignancy, and briefly the treatment methods, according to the current studies from literature.