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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 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 Anatomical, Functional, and Dynamic Evidences Obtained byIntraoperative Neuromonitoring Improving the Standards ofThyroidectomy(2021) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri ÜniversitesiThe use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage ofIONM regarding the laryngeal nerves’ anatomy and function have provided important contributions for improving the standardsof the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrentlaryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations ofRLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquiredregarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innerva tion of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and givesmotor 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 tothe anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicatingnerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid musclewhich is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to themotor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is themost common reason of RLN injuries and constitutes of 67–93% of cases. More than 50% of EBSLN injuries are caused by nervetransection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the lossof signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cordparalysis (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 andpermanent 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-RLNaxis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makessignificant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerveinjury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.Publication Open Access Parathyroidectomy Results in Primary Hyperparathyroidism:Analysis of the Results From a Single Center(2021) Yetkin, Gürkan; Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Akgün, İsmail Ethem; Ünlü, Mehmet Taner; Erol, Rümeysa Selvinaz; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; T.C. Sağlık Bakanlığı; Sağlık Bilimleri ÜniversitesiObjectives: The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may de velop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery forPHPT in our clinic. Methods: The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidec tomy 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 inour 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%) hadcure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS wasperformed to 10 patients (90.9%), partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these pa tients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Fourpatients 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 evaluationand 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 curerate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.Publication Open Access Substernal Goiter: From Definitions to Treatment(2022) Aygün, Nurcihan; Uludağ, Mehmet; İşgör, Adnan; Köstek, Mehmet; Ünlü, Mehmet Taner; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri Üniversitesi; Bahçeşehir Üniversitesi; Sağlık Bilimleri Üniversitesi; Sağlık Bilimleri ÜniversitesiThe enlargement of multinodular goiter into the mediastinum through the thoracic inlet or ectopic thyroid tissues directly in the \rmediastinum is defined as Substernal Goiter (SG). However, there is no clear consensus in the literature on this definition. There \rare many definitions for SG in the literature. Most definitions are similar or overlapping. Since the thyroid is located in the neck \rabove 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 \rguideline, SG is defined as clinical or radiological protrusion of the thyroid gland over the sternal notch or clavicle in a patient with \ra 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 \rtoward the mediastinum, and the secondary SG, which is defined as an ectopic mediastinal mass, together. We find it appropriate \rto define such SGs as mixed SGs. In this disease, which has the same etiology and etiopathogenesis as cervical goiter, the descent \rof the thyroid gland into the mediastinum due to some anatomical factors explains the physiopathology. Compression symptoms \rof mediastinal major vascular structures, trachea, and esophagus cause the symptoms and findings of SGs due to its localization. \rIn addition, the relationship of SGs with possible malignancy risk and hyperthyroidism affecting the indications and methods of \rtreatment has been discussed for a long time. In this study, we aimed to evaluate the definitions, classification, physiopathology, \rlaboratory and imaging methods used for diagnosis, the relationship of SG with hyperthyroidism and malignancy, and briefly the \rtreatment methods, according to the current studies from literature.