2025 国际专家共识：良性甲状腺结节的热消融治疗

Introduction

Thyroid nodules are a common condition with reported incidence ranging from 34% to 66%[1-8]. The widespread application of high-frequency ultrasound has further contributed to the increasing incidence of thyroid nodules. An epidemiological study from China reported that the overall prevalence of thyroid nodules was 36.9% among 6 985 956 individuals who underwent thyroid ultrasound during routine health examinations[8]. Notably, approximately 90% of these nodules are benign thyroid nodules (BTNs)[2]. Most BTNs do not require intervention, and medical treatment is often necessary for nodules that present with compression symptoms, cosmetic concerns, retrosternal positioning, or dimensions exceeding 4–5 cm[9-11]. Although thyroidectomy remains the traditional treatment approach, it has notable disadvantages, including extensive perithyroidal soft tissue damage, visible neck scarring, iatrogenic hypothyroidism, and neck and shoulder discomfort, all of which can substantially diminish patients’ quality of life.

Thermal ablation (TA) has become a widely used treatment for thyroid nodules over the past two decades. In 2002, laser ablation (LA) was first reported as a useful nonsurgical alternative for BTNs$^{[12]}$. In 2006, the effectiveness and safety of radiofrequency ablation (RFA) for BTNs were first reported[13]. Microwave ablation (MWA) was first reported as a treatment with satisfactory efficacy and safety for BTNs in 2012[14]. Following these initial explorations, TA has experienced rapid development in the treatment of BTNs.

Currently, multiple prospective and retrospective studies have validated both the safety and efficacy of TA in treating these nodules (Supplemental Digital Content Table 1, available at: http://links.lww.com/JS9/G707). This procedure effectively reduces BTN volume, alleviates compression symptoms, and addresses cosmetic concerns while maintaining a low complication rate. Compared with thyroidectomy, TA offers several advantages, including no scars, improved postprocedure recovery, and minimal risk of requiring lifelong hormone replacement therapy. Moreover, many studies have reported that TA is more cost-effective than thyroidectomy[15-19], and TA has become an increasingly popular choice for patients with thyroid nodules[20,21].

Several guidelines and consensuses have recommended TA as an alternative treatment option for BTNs[22-34]. However, they still have shortcomings in the comprehensive management of the whole process of TA for BTNs. For example, most consensus statements have not addressed operator training[22-25,27,31,33-35]. More importantly, the current consensus and guidelines primarily derive TA indications from surgical criteria, which typically focus on larger, symptomatic BTNs[23-25,27,39,30,33-35]. However, TA is an entirely different technique compared with thyroidectomy (Supplemental Digital Content Table 2, available at: http://links.lww.com/JS9/G708 and Supplemental Digital Content Table 3, available at: http://links.lww.com/JS9/G709). TA does not provide immediate removal of BTNs, which may lead to less satisfactory therapeutic efficacy in the short term, particularly

HIGHLIGHTS

$\bullet$ Thermal ablation (TA) is recommended as first-line treatment for 2–4 cm solid or predominantly solid benign thyroid nodules (BTNs). $\bullet$ TA for large BTNs >4 cm is technically challenging with higher risk and lower efficacy. $\bullet$ Planned staged TA is recommended for large BTNs >4 cm when surgery is not feasible. $\bullet$ Chemical ablation is preferred for symptomatic cystic or predominantly cystic BTNs. $\bullet$ TA is an alternative if chemical ablation fails for symptomatic cystic BTNs.

for symptomatic or large BTNs. According to the literature and clinical experience, TA for larger BTNs results in a lower volume reduction rate (VRR), a lower rate of complete disappearance, a higher risk of repeat TA, and a higher risk of complications, such as thyroid nodule rupture (TNR)[36-42]. These factors can significantly impact patients' satisfaction with TA for BTNs. In contrast, relatively smaller BTNs, such as those with diameters <2.5 cm, could have higher VRR, a higher incidence of complete disappearance, and lower complication risks[43]. Therefore, the conventional surgical indications for BTNs may not be applicable to TA. It is crucial to establish novel and specific indications for TA in BTNs that highlight its advantages and enhance clinical feasibility.

To address these gaps, the present consensus was developed through extensive discussions, comprehensive literature reviews, and expert evaluations, aiming to provide up-to-date and standardized guidance on the use of TA for BTNs, particularly in identifying the optimal indications for its application. This consensus represents a pivotal step toward more effective and evidence-based management of TA for BTNs.

Artificial intelligence (AI) or AI-assisted technologies were not used in the writing process, and the present consensus was reported in line with the TITAN guidelines[44].

Materials and methods

Scope and target population

This consensus focuses on the TA for nonfunctioning BTNs and does not discuss autonomously functioning or toxic thyroid nodules.

The target audiences for this consensus are operators from different specialty backgrounds who perform or intend to perform TA for BTNs.

Expert panel formation

The development of the present consensus was initiated by XXX. A panel of globally renowned experts specializing in TA for thyroid nodules was established. This panel was carefully selected to represent the perspectives of surgeons, radiologists, endocrinologists, and nuclear medicine specialists regarding the TA for BTNs. The criteria for expert selection included meeting at least one of the following criteria: (1) having published at least five research studies related to TA for thyroid nodules; (2) extensive clinical experience with TA for thyroid nodules,

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completing at least 50 BTN ablation procedures per year; and (3) substantial involvement in clinical research on percutaneous TA for tumors and reporting relevant results. Additionally, each author has been recognized as an expert in at least one domestic or international association or society in fields related to TA for tumors. Based on these criteria, a panel of 30 distinguished experts was established, including 18 from Asia, 7 from Europe, 1 from North America, 3 from South America, and 1 from Africa. With respect to the specialties of the experts, there were 9 surgeons, 17 radiologists, 1 nuclear medicine specialist, 2 endocrinologists, and 1 oncologist. Details regarding the experts' affiliations and qualifications are provided in the supplementary file (Supplemental Digital Content, available at: http://links.lww.com/JS9/G887, Qualification of Experts).

Literature review

A comprehensive literature review on the TA for BTNs was conducted. The search terms were taken from Medical Subject Headings (MeSH). MeSH terms and entry terms of “thyroid nodules” were combined with the MeSH terms and entry terms of “ablation techniques” or “microwaves” or “radiofrequency therapy” or “laser therapy.” Electronic databases, including PubMed, Embase, Ovid, Cochrane, and Web of Science, were searched. The publication time was between January 2000 and April 2024. The specific search strategy is detailed in the supplementary file (Supplemental Digital Content, available at: http://links.lww.com/JS9/G706, Search Strategy). The reference lists of the included articles were also screened to identify additional relevant studies.

The study inclusion criteria were as follows: (i) participants: patients with a pathological diagnosis of BTNs; (ii) intervention: ablation treatment (including MWA, RFA, and LA); (iii) outcome: VRR, symptom evaluation, local recurrence rate, technique success rate, complications and quality of life; and (iv) studies published in English. The exclusion criteria were as follows: (i) absence of treatment or follow-up data; (ii) TA for autonomously functioning or toxic thyroid nodules; (iii) high-intensity focused ultrasound; (iv) full-text could not be obtained; (v) ineligible article types: conference abstract, book, comment, editorial and letter; and (vi) repeated publication. After the duplicates were removed, the titles and abstracts were screened for inclusion. The full text was reviewed when the title or abstract was ambiguous. Finally, 341 eligible studies were included in the literature review (Fig. 1). The details of the studies with sample sizes greater than 100 are provided in the supplementary table (Supplemental Digital Content Table 1, available at: http://links.lww.com/JS9/G707).

The full texts of the included articles were reviewed. The relevant data, including the first author's last name, publication year, country, ablation technique, study design, sample size, baseline information, BTN size, and other characteristics, follow-up data, efficacy indicators, complications, and major findings, were extracted and verified. All the missing or unclear information needed was marked as unspecified. For inconsistent reporting, we extracted the higher-quality, most conservative, and most clearly defined results. The risk of bias in the studies was evaluated using the Newcastle-Ottawa Scale

![graph TD\n A1[Records identified from: PubMed(n=580) Web of Science(n=597) Embase(n=222) Ovid(n=880) Cochrane(n=33)] --> A2[Records screened(n = 1387)]\n A2 --> A3[Records excluded: Not in the field of interest(n=701) Non-English literature(n=28) Duplication(n=42) Comments/abstract/letter(n=204)]\n A2 --> A4[Reports sought for retrieval(n = 412)]\n A3 --> A4\n A4 --> A5[Reports not retrieved(n = 7)]\n A4 --> A6[Reports assessed for eligibility(n = 405)]\n A5 --> A6\n A6 --> A7[Studies included in review(n = 341)]\n A6 --> A8[Ineligible reports(n = 341)]\n A7 --> A9[Development of initial 26 recommendations in 8 aspects: after online and in person discussion among experts in drafting group]\n A8 --> A9\n A10[Expert Panel Formation(n=30)] --> A11[First Round of Delphi Survey: The Delphi questionnaire was distributed to the expert panel with a two-week deadline(n = 26 recommendations). A reminder email was sent one week before the deadline.]\n A11 --> A12[Modification of the recommendations: The recommendations were revised according to score and suggestions in Delphi survey. Clear feedback was given to each suggestion and comment in first round after discussion among drafting group.]\n A11 --> A13[First Delphi Survey: Each recommendation was rated on a 9-point Likert scale(1=strong opposition, 5=neutral, 9=strong agreement). Open-ended suggestions for improvement were encouraged, especially for recommendations scoring 4 or below.]\n A12 --> A13\n A12 --> A14[Second Round of Delphi Survey: The revised recommendations, average scores, score distributions, anonymized comments from panelists, and corresponding feedback from the first round were distributed to the expert panel with a two-week deadline(n = 26 recommendations). A reminder email was sent one week before the deadline.]\n A13 --> A14\n A14 --> A15[Modification of the recommendations: The recommendations were revised according to score and suggestions in Delphi survey. Clear feedback was given to each suggestion and comment in first round after discussion among drafting group.]\n A14 --> A16[Second Delphi Survey: Each recommendation was rated on a 9-point Likert scale. Open-ended suggestions on revised recommendations and all anonymized comments from the first round were encouraged, particularly for those scoring 4 or below.]\n A15 --> A16\n A15 --> A17[Expert Consensus Symposium: Experts in Delphi survey and drafting group participated in-person discussions on the recommendation, score, and comments from Delphi Survey.]\n A16 --> A17\n A17 --> A18[Final Modification of the recommendations: The recommendations were revised based on score and suggestions from expert consensus symposium.]\n A18 --> A19[Final consensus with 26 Recommendations]\n](1/parseimages/figure3c16992ae3f2422cbba6655f43a04068_0_6.png) Cao et al. International Journal of Surgery (2026)

International Journal of Surgery

for nonrandomized studies and the Cochrane Risk of Bias Tool for randomized controlled studies.

The literature screening, review, data extraction, verification, and risk of bias evaluation were independently conducted by two researchers, with any discrepancies resolved by a third researcher.

Recommendation construction

Initially, experts from the drafting group provided recommendations based on comprehensive literature reviews and clinical experience, which focused on eight key aspects of TA for BTNs: (1) operator qualification and ability advancement; (2) preablation evaluation; (3) indications and contraindications; (4) preablation preparation; (5) ablation procedure; (6) postablation management; (7) effectiveness; and (8) complications.

After multiple rounds of evaluation and discussion within the drafting group, necessary additions and deletions, 26 preliminary recommendations on TA for BTNs were drafted for the Delphi survey. The manuscript of the recommendations, explanations, and corresponding references was sent to panelists for Delphi scoring and revision. The drafting group members did not participate in the Delphi survey.

Delphi survey and consensus process

Three rounds of Delphi surveys and recommendation revisions were subsequently performed to refine these recommendations by the expert panel[45-47]. A nine-point Likert scale was used in the Delphi survey, and each recommendation was rated from 1 to 9 points (strongly disagree to strongly agree).

In the first round, the panelists rated the recommendations and provided comments. In the second round, the comments and different opinions from the first round were considered, and the recommendations were revised and formulated for further assessment on the basis of the same rating system previously used.

After two iterative phases of gathering suggestions, an in-person meeting of the expert panel was held to deliberate on the proposed recommendations and to establish the present consensus. A consensus was established when more than 70% of the panelists rated the proposed recommendation between 7 and 9 points at the final meeting. This process effectively integrated diverse expert opinions and refined the present consensus. A flowchart of the consensus formation process is shown in

Figure 1, and the detailed Delphi survey process is presented in the supplementary file (Supplemental Digital Content, available at: http://links.lww.com/JS9/G704, Delphi Survey and Consensus Process).

The strength of the recommendations was determined by the final Delphi score. This score reflects the potential clinical benefit of the recommendation based on the clinical experience of the expert panel. The evidence level of the recommendations was determined based on the quality of the supporting studies with respect to design, methodological rigor, and risk of bias. The criteria for the grade and evidence level of the recommendations in the present study are shown in Table 1.

Results

Following three rounds of Delphi surveys, including in-person discussions among the expert panel, the present consensus resulted in 26 recommendations across 8 aspects. The final recommendations are presented in Table 2, and the Delphi scores of each recommendation are presented in Table 3.

Operator qualification and ability advancement

Learning curves associated with TA for thyroid nodules affect therapeutic effectiveness and safety[48-51]. Operators who intend to perform TA for thyroid nodules come from diverse specialties and should adhere to stringent standards to ensure its effectiveness and safety[52,53]. The technique improvements should be implemented step by step as follows:

1. Expertise in neck ultrasound examination: Operators should be proficient in ultrasound examination of the neck, with particular emphasis on the diagnosis of thyroid nodules and detailed knowledge of the thyroid anatomy and adjacent structures.

2. Expertise of ultrasound-guided thyroid nodule biopsy: Operators should have extensive experience in ultrasound-guided thyroid nodule biopsies. The operator should be adept at coordinating both hands to synchronize probe scanning, guidance, and needle puncture.

3. Expertise of ultrasound-guided chemical ablation for thyroid nodules: Operators are advised to perform chemical ablation on mixed or cystic BTNs before attempting TA.

Table 1

Levels of evidence and grades of recommendation

Grade of recommendation

A. Strong recommendation: Delphi score 8.0-9.0

B. Moderate recommendation: Delphi score 7.0-7.9

C. Weak recommendation: Delphi score 6.0-6.9

D. Neutral: Delphi score 5.0-5.9

E. Oppose: Delphi score 1.0-4.9

Level of evidence

High A. Evidence from at least one large controlled trial of good methodological quality (low risk of bias) or a meta-analyses of well-conducted randomized trials without heterogeneity

B. Small randomized controlled trials or large controlled trials with a risk of bias (lower methodological quality) or meta-analyses of such trials C. Prospective comparative studies; retrospective comparative studies with balanced baseline characteristics (using propensity score matching, etc.)

Moderate D. Case-control studies; retrospective cohort studies

Low E. Studies without a control group, case reports, or expert opinions

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Table 2

Summary of recommendations

Operator qualification and ability advancement

1. The TA for BTNs requires a high level of technical skill. Operators are recommended to pursue a competence improvement pathway, beginning with neck ultrasound examination, thyroid nodule diagnostics, biopsy procedures, and progression to ablation techniques, to improve their technical proficiency (Strong recommendation, moderate-quality evidence).

Preablation evaluation

2. Evaluation of symptoms related to BTNs is essential before TA (Strong recommendation, high-quality evidence).

3. Routine laboratory examinations, including thyroid function tests, complete blood tests, and coagulation function tests, should be conducted before TA (Moderate recommendation, moderate-quality evidence).

4 High-frequency ultrasound examination is recommended for assessing BTNs, including the imaging characteristics of the target BTNs and their relationships with surrounding vital structures (Strong recommendation, high-quality evidence).

5 Neck and chest CT or MRI is recommended for patients with retrosternal BTNs (Moderate recommendation, moderate-quality evidence).

6 $\circ$ in patients without voice problems or a related history, laryngeal ultrasound is recommended for evaluating RLN function through the observation of vocal fold mobility before the TA of BTNs. ② For patients with voice problems or related medical histories, laryngoscopy is recommended for evaluating RLN function (Strong recommendation, high-quality evidence).

Indications and contraindications

7 TA is recommended as one of first-line treatments for mixed or solid BTNs between 2 and 4 cm (Moderate recommendation, high-quality evidence).

8. The expert panel did not reach a consensus on the routine use of TA for BTNs smaller than 2 cm. However, it may be considered in specific clinical scenarios, such as rapid growth, associated symptoms, and multiple nodules, following a comprehensive patient-doctor discussion on the clinical benefit and risk of complications (Weak recommendation, moderate-quality evidence).

9. Planned staged TA is a treatment option for BTNs adjacent to vital structures where hydrodissection is difficult, as well as for large BTNs (>4 cm) or retrosternal BTNs (Moderate recommendation, high-quality evidence).

10. Symptomatic cystic or predominantly cystic BTNs are recommended to be treated with chemical ablation first, and TA is recommended if chemical ablation fails (Strong recommendation, high-quality evidence).

Preablation preparation

11 Written informed consent is mandatory before TA for BTNs (Strong recommendation, high-quality evidence).

12 Patient education before TA is important for increasing patients' acceptance of TA, reducing their anxiety, and improving their cooperation during TA (Strong recommendation, high-quality evidence).

13. Standard clean interventional rooms, high-frequency ultrasound equipment, ablation instruments, emergency equipment, and medications should be available to ensure the safety and effectiveness of TA (Strong recommendation, high-quality evidence).

Ablation procedures

14. Ultrasound examination should be performed before TA to develop the procedure plan, including identifying the target BTNs and determining the sequence of the TA for multiple BTNs (Strong recommendation, high-quality evidence).

15 Local anesthesia of the skin and thyroid capsule is recommended before TA (Strong recommendation, high-quality evidence).

16 TA for BTNs should be performed methodically and sequentially, beginning from the deeper part of the BTNs and gradually moving toward the superficial part (Strong recommendation, moderate-quality evidence).

17 For bilateral BTNs, the BTNs on the safer side (far from the RLN) should be ablated first, and RLN function should be confirmed to be normal before proceeding to the contralateral BTNs (Strong recommendation, moderate-quality evidence).

18. Hydrodissection based on perithyroidal fascial spaces is a key factor to ensure the safety of TA and should be performed in all cases (Strong recommendation, moderate-quality evidence).

19 A conformal TA is recommended for BTNs (Strong recommendation, moderate-quality evidence).

20 B-mode US, CDFI, CEUS, or MFI is recommended for evaluating the effectiveness of TA depending on the operators' preference and available resources (Strong recommendation, moderate-quality evidence).

21 High-frequency ultrasound is recommended for evaluating RLN function during and after TA (Strong recommendation, high-quality evidence).

#

22 Patients with BTNs after TA should receive regular follow-up with ultrasound and/or thyroid function examinations (1, 6, and 12 months after TA and then annually thereafter) (Strong recommendation, moderate-quality evidence).

Effectiveness

23 Evaluating the efficacy of BTNs after TA from three dimensions is recommended. A successful TA of BTNs should meet one of the following criteria: ① complete ablation; ② VRR ≥50%; and ③ BTN-related symptoms either disappeared or were significantly alleviated (Strong recommendation, high-quality evidence).

Complications

24 Hydrodissection and ablation power control should be employed to reduce the risk of RLN injury (Strong recommendation, moderate-quality evidence).

2. ① In cases of active hemorrhage, TA is recommended for hemostasis, and ② for mild hemorrhage, hemostatic drugs and local compression are recommended for hemostasis (Strong recommendation, moderate-quality evidence).

26 To avoid TNR, a rare but major complication, patients should be educated to avoid local mechanical pressure on the BTN after TA, especially for patients with large BTNs (Moderate recommendation, moderate-quality evidence).

BNTs, benign thyroid nodules, CDFI, color Doppler flow imaging, CEUS, contrast enhanced ultrasound, MFI, micro-flow imaging, RLN, recurrent laryngeal nerve, TA, thermal ablation, TNR, thyroid nodule rupture, US, ultrasound, VRR, volume reduction rate.

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Table 3

|Recommendation|Average score|Delphi scores distribution||| |---|---|---|---|---| |Recommendation|Average score|1-3 (n/%)|4-6 (n/%)|7-9 (n/%)| |1. Operator qualification and ability advancement||||| |Recommendation 1|8.5|0 (0)|3 (10.0)|27 (90.0)| |2. Pre-ablation evaluation||||| |Recommendation 2|8.2|1 (3.3)|2 (6.7)|27 (90.0)| |Recommendation 3|7.4|3 (10.0)|4 (13.3)|23 (76.7)| |Recommendation 4|8.9|0 (0)|0 (0)|30 (100.0)| |Recommendation 5|7.9|0 (0)|3 (10.0)|27 (90.0)| |Recommendation 6|8.5|0 (0)|3 (10.0)|27 (90.0)| |3. Indications and contraindications||||| |Recommendation 7|7.8|1 (3.3)|5 (16.7)|24 (80.0)| |Recommendation 8|6.4|2 (6.7)|10 (33.3)|18 (60.0)| |Recommendation 9|7.7|1 (3.3)|3 (10.0)|26 (86.7)| |Recommendation 10|8.3|1 (3.3)|1 (3.3)|28 (93.3)| |4. Pre-ablation preparation||||| |Recommendation 11|8.8|0 (0)|0 (0)|30 (100.0)| |Recommendation 12|8.9|0 (0)|0 (0)|30 (100.0)| |Recommendation 13|8.6|0 (0)|1 (3.3)|29 (96.7)| |5. Ablation procedures||||| |Recommendation 14|8.8|0 (0)|1 (3.3)|29 (96.7)| |Recommendation 15|8.6|0 (0)|1 (3.3)|29 (96.7)| |Recommendation 16|8.7|0 (0)|1 (3.3)|29 (96.7)| |Recommendation 17|8.4|0 (0)|3 (10.0)|27 (90.0)| |Recommendation 18|8.5|1 (3.3)|1 (3.3)|28 (93.3)| |Recommendation 19|8.2|0 (0)|3 (10.0)|27 (90.0)| |Recommendation 20|8.2|0 (0)|3 (10.0)|27 (90.0)| |Recommendation 21|8.0|1 (3.3)|4 (13.3)|25 (83.3)| |6. Post-ablation management Recommendation 22|8.2|0 (0)|1 (3.3)|29 (90.0)| |7. Effectiveness||||| |Recommendation 23|8.6|0 (0)|1 (3.3)|29 (96.7)| |8. Complications||||| |Recommendation 24|8.5|1 (3.3)|0 (0)|29 (96.7)| |Recommendation 25|8.1|0 (0)|4 (13.3)|26 (86.7)| |Recommendation 26|7.8|0 (0)|5 (16.7)|25 (83.3)|

4. Skills in hydrodissection based on perithyroidal fascial spaces: To ensure the safety of TA, operators should be proficient in ultrasound-guided hydrodissection based on perithyroidal fascial spaces[54,55].

5. Mastery of ablation equipment: Operators should be adept at using various ablation equipment, including microwave, radio-frequency, or laser devices. Knowledge of the relevant principles, power settings, and corresponding ablation zones is necessary.

6. Ablation techniques: Operators should be skilled in advanced ablation techniques, such as fixed-applicator, multipoint, and moving-shot ablation[56–58].

7. Competence improvement pathway: Operators should follow a structured progression pathway, beginning with TA for relatively small lesions (≤3 cm) under the guidance of doctors who have rich experience with TA, and then for relatively larger lesions and more complex cases, such as

BTNs near the recurrent laryngeal nerve (RLN), the Zuckerkandl tubercle, and larger BTNs.

Recommendation 1: The TA for BTNs requires a high level of technical skill. Operators are recommended to pursue a competence improvement pathway, beginning with neck ultra-sound examination, thyroid nodule diagnostics, biopsy procedures, and progression to ablation techniques, to improve their technical proficiency (Strong recommendation, moderate-quality evidence).

Preablation evaluation

Symptom evaluation

Some patients with BTNs may experience symptoms such as dyspnea, dysphagia, or dysphonia due to compression, and large BTNs can also lead to cosmetic concerns. A detailed medical history is recommended to accurately assess preablation symptoms, which is essential for evaluating the indication and effectiveness of TA. Some instruments can be used to comprehensively evaluate thyroid-related symptoms, such as the Thyroid-Related Patient-Reported Outcome (Thy PRO)[59] and ThyRO short form (Thy PRO-39)[60].

Laboratory examinations

1. General tests: Routine examinations should include full blood count and bagulation function tests. A platelet count >50 × 10$^{9}$/L and an international normalized ratio <-1.5-1.8 are generally recommended to reduce the risk of hematoma during TA for BTNs[61-63].

Thyroid-specific tests: Essential assessments should measure free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) levels. Additionally, tests for thyroid antibodies, such as thyroid peroxidase antibody, thyroidglobulin antibody, and TSH receptor antibody (TRAb), are suggested before TA for BTNs, especially for suspected autoimmune thyroid diseases, such as Hashimoto's thyroiditis and Graves' disease.

2. Other tests, such as infectious disease screening (HBV, HCV, HIV, and syphilis), may be performed when required by legal regulations or for patients with suspected infectious diseases. Laboratory examinations related to the liver, kidney, heart, or other organs should be conducted before TA in patients with relevant medical histories.

Imaging examinations

1. Ultrasound: High-frequency ultrasound (≥7.5 MHz[64]) is recommended for assessing the imaging characteristics of BTNs and their relationship with vital surrounding structures (e.g. the trachea, esophagus, RLN, and cervical muscles). However, low-frequency ultrasound is useful for evaluating deep BTNs. The Thyroid Imaging Reporting and Data System (TI-RADS) or similar effective tools are suggested to assess the malignancy risk of thyroid nodules[65-67].

2. Computed tomography (CT) or magnetic resonance imaging (MRI): Neck and chest CT or MRI is recommended for retrosternal $BTNs^{[68-71]}$, as these techniques are valuable

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for assessing the retrosternal portion. For large BTNs, CT or MRI is advised in patients with respiratory symptoms or suspected tracheal compression to evaluate the relationship of the BTN with the trachea[72-75].

Pathological examination

A specific pathological diagnosis of target thyroid nodules should be identified before TA. Fine-needle aspiration (FNA) is recommended for cytological examination, and mutation testing (BRAFV600E) is also recommended for a comprehensive diagnosis[76,77]. The cytopathological results should be reported and illustrated with the Bethesda System or similar effective tools[76]. Additionally, operators should be aware of the limitations and accuracy issues when interpreting the TIRADS and Bethesda classifications[78-80]. Core needle biopsy (CNB) can be performed for histological examination when necessary, such as when the cytopathological result is inconsistent with the ultrasound results.

Other auxiliary examinations

1. RLN function evaluation: For patients with voice problems or related histories, laryngoscopy is recommended for assessing RLN function. For patients without voice problems or a related history, laryngal ultrasound is recommended for assessing RLN function through the observation of vocal fold mobility[81,82]. Additionally, laryngoscopy is advised for patients in whom the vocal folds are not clearly visualized on ultrasound[82].

2. Other considerations: To avoid nonprocedure complications, a detailed medical history should be obtained, and relative examinations should be conducted for patients with severe comorbidities. For example, cardiac enzyme analysis, coronary artery CT angiography, or other specialist cardiac examinations are recommended for patients with coronary atherosclerotic heart disease, and arterial blood gas analysis is recommended for patients with severe chronic obstructive pulmonary disease.

Recommendation 2: Evaluation of symptoms related to BTNs is essential before TA (Strong recommendation, high-quality evidence).

Recommendation 3: Routine laboratory examinations, including thyroid function tests, complete blood tests, and coagulation function tests, should be conducted before TA (Moderate recommendation, high-quality evidence).

Recommendation 4: High-frequency ultrasound examination is recommended for assessing BTNs, including the imaging characteristics of the target BTNs and their relationships with surrounding vital structures (Strong recommendation, high-quality evidence).

Recommendation 5: Neck and chest CT or MRI is recommended for patients with retrosternal BTNs (Moderate recommendation, moderate-quality evidence).

Recommendation 6: ① In patients without voice problems or a related history, laryngeal ultrasound is recommended for evalu-uating RLN function through the observation of vocal fold mobility before the TA of BTNs. ② For patients with voice problems or related medical histories, laryngoscopy is recommended for evaluating RLN function (Strong recommendation, high-quality evidence).

Indications and contraindications

Indications

Based on the expert experience and the literature [52,53,56,57,83-92], TA is recommended as one of first-line treatments for predominantly solid or solid BTNs between 2 and 4 cm in size. For mixed BTNs, if color Doppler flow imaging (CDFI) or contrast-enhanced ultrasound (CEUS) reveals a lack of blood supply in the solid component, chemical ablation may be considered the preferred treatment. For BTNs adjacent to vital structures where effective hydrodissection is challenging or for large BTNs (>4 cm) or retrosternal BTNs, planned staged TA is recommended as a treatment option when patients refuse or delay surgery [89,93,94].

Predominantly cystic or cystic BTNs larger than 2 cm are recommended for initial treatment with chemical ablation (primarily including ethanol or polidocanol ablation) [91,92,95,96]. TA is recommended for patients with unsatisfactory therapeutic outcomes following chemical ablation [97].

Although some studies have enrolled BTNs less than 2 cm in size and treated with TA[36,98-101], the expert panel did not reach a consensus on the routine use of TA for BTNs smaller than 2 cm, particularly those between 1.5 and 2 cm. Some experts believe that it is reasonable to employ TA for BTNs smaller than 2 cm, especially for those with rapid growth, related symptoms, and multiple BTNs. Conversely, other experts express concerns about potential overtreatment.

Clinical studies and expert experience have indicated that TA for larger BTNs often presents technical challenges, potentially leading to a higher incidence of complications, a lower VRR and a lower complete disappearance rate of the ablation zone[36-40,43,102,103]. In contrast, TA for smaller BTNs might yield safer and more effective clinical outcomes, such as lower complication rates, higher VRR, and complete disappearance rates. Therefore, the application of TA for BTNs smaller than 2 cm should be evaluated based on the medical conditions, the development and acceptance of minimally invasive treatments in various countries.

Importantly, the decision regarding TA for BTNs smaller than 2 cm should be made collaboratively by patients and doctors, following comprehensive discussions about the advantages and potential risks associated with the TA.

Contraindications

The contraindications of TA for BTNs are as follows: ① mental disorders or consciousness disturbances affecting cooperation during TA; ② diseases limiting neck extension during TA; ③ high risk of bleeding during TA, such as severe coagulation dysfunction, thrombocytopenia (platelet count <60 × 10$^{9}$/L), or an insufficient anticoagulant discontinuation period; and ④ severe cardiopulmonary dysfunction, such as acute myocardial infarction, acute heart failure, severe acute asthma, or other diseases impeding horizontal positioning during TA.

Relative contraindications: ① Large BTNs (>4 cm): TA for large BTNs is associated with a higher risk of complications, but TA could be considered a temporary or staged control method for patients who are refusing or delaying surgery[89,93,94]; ② large retrosternal BTN: TA is not routinely recommended for large retrosternal BTNs because they are difficult to fully visualize with ultrasound; however,

Cao et al. International Journal of Surgery (2026)

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experienced operators may perform staged or partial TA;⑤ unrecovered RLN dysfunction: TA is not recommended for BTNs on the contralateral lobe in patients with unrecovered RLN dysfunction.

Recommendation 7: TA is recommended as one of first-line treatments for mixed or solid BTNs between 2 and 4 cm (Moderate recommendation, high-quality evidence).

Recommendation 8: The expert panel did not reach a consensus on the routine use of TA for BTNs smaller than 2 cm. However, it may be considered in specific clinical scenarios, such as rapid growth, associated symptoms, and multiple nodules, following a comprehensive patient-doctor discussion on the clinical benefit and risk of complications (Weak recommendation, moderate-quality evidence).

Recommendation 9: Planned staged TA is a treatment option for BTNs adjacent to vital structures where hydrodissection is difficult, as well as for large BTNs (>4 cm) or retrosternal BTNs (Moderate recommendation, high-quality evidence).

Recommendation 10: Symptomatic cystic or predominantly cystic BTNs are recommended to be treated with chemical ablation first, and TA is recommended if chemical ablation fails (Strong recommendation, high-quality evidence).

Preablation preparation

Patient education and psychological support

Patient education and written informed consent are essential before TA[104-107]. Patients should be informed of the general process and advantages of TA to improve their understanding of the procedure, increase their confidence, and alleviate anxiety. Additionally, patients need to be informed about the limitations and potential complications of TA, as well as the corresponding management strategies and prognosis.

Ablation equipment and medication preparation

1. Interventional room standard: The interventional room should be clean and regularly disinfected. Basic medical instruments, such as patient monitoring and oxygen delivery equipment, are useful for ensuring the safety of TAs. 2. Ultrasound equipment with high-frequency probes, ablation equipment, and auxiliary consumables, such as sterile probe covers, coupling agents, needles, catheters, and injection syringes used for hydrodissection, should be prepared.

3. Emergency preparedness: Basic and advanced life support drugs and equipment, such as cardiovascular drugs, tracheal intubation devices, defibrillators, and other emergency vehicles, should be readily available.

Recommendation 11: Written informed consent is mandatory before TA for BTNs (Strong recommendation, high-quality evidence).

Recommendation 12: Patient education before TA is important for increasing patients' acceptance of TA, reducing their anxiety, and improving their cooperation during TA (Strong recommendation, high-quality evidence).

Recommendation 13: Standard clean interventional rooms, high-frequency ultrasound equipment, ablation instruments, emergency equipment, and medications should be available to ensure the safety and effectiveness of TA (Strong recommendation, high-quality evidence).

Ablation procedures

Ultrasound assessment

The number, location, size, and other characteristics of the target BTN on ultrasound should be confirmed and documented before TA. CDFI, CEUS, or microflow imaging (MFI) could be used to further evaluate the blood supply, especially for mixed cystic-solid BTNs, which is helpful in developing a specific treatment plan.

Anesthesia

Local anesthesia of the skin and thyroid capsule is recommended before TA for BTNs[108-110]. To avoid RLN anesthesia, local anesthesia should not be administered near the RLN pathway. Intravenous anesthesia, conscious sedation, and/or analgesics can be used for patients for whom local anesthesia is ineffective[108,109].

Hydrodissection based on perithyroidal fascial spaces

Hydrodissection based on perithyroidal fascial spaces is highly recommended during TA for BTNs[54,55,111,112]. A satisfactory isolation distance should be at least 5 mm[54,113] and should be maintained via continuous injection during ablation[111]. With respect to large BTNs, the isolation liquid can be continuously

 Cao et al. International Journal of Surgery (2026)

injected after the TA to absorb accumulated heat and prevent delayed RLN injury, particularly in paratracheal spaces.

There are three perithyroidal fascial spaces for hydrodissection[54] (Fig. 2): ① the anterior space, located between the anterior thyroid capsule and the anterior cervical strap muscle; ② the posterior space, located between the posterior thyroid capsule and the carotid sheath or longus colli muscle; and ③ the paratrachal space, located between the medial thyroid capsule and the trachea. The fascial spaces for hydrodissection should be selected based on the location of the target BTNs.

Ablation strategy

1. Unifocal target BTN: The TA should begin from the deeper part of the BTN and gradually move toward the superficial part to prevent hyperechoic gas bubbles from masking deeper remnant areas during the TA.

2. Multifocal target BTN: For unilateral BTNs, TA of deeper lesions is recommended first. For bilateral BTNs, it is recommended to ablate the lesions on the safe side first (those located far from the RLN); then, the contralateral side should be treated only if RLN function is confirmed to be normal via ultrasound. If the RLN function is impaired, TA for BTNs on the contralateral side should be deferred until recovery.

3. Mixed nodules: The solid component is recommended to be treated first. For predominantly cyst BTNs, the cystic components should be aspirated first, followed by chemical ablation and/or TA. If the cystic composition is difficult to aspirate, TA can be performed directly. For predominantly solid BTNs, TA can be performed directly.

Disinfection and preparation

Disinfection and surgical drape are highly recommended. The disinfection range should extend at least to the lower lip at the head side edge, the nipple at the caudal side edge, and the anterior axillary line, as well as the posterior lateral neck on both sides.

Intravenous infusion access could be established before TA. Peripheral oxygen saturation, electrocardiogram, and blood pressure should be monitored during TA.

Ablation procedure

A 0.3-0.5 cm active tip antenna with a maximum power of 30-40 W is recommended for MWA. A 0.7-1.0 cm active tip electrode with a maximum power of 40-60 W is recommended for RFA. A 300 µm diameter plane-cut optical fiber and 21 gauge introducer needle with a power of 3-5 W are recommended for LA, with a total delivered energy of 1200-1800 J for each illumination. The tip of the optical fiber should pro-trude 5 mm from the introducer needle tip. Multipoint or mov-ing shot ablation should be selected based on the characteristics of the target BTNs and operator preference.

Conformal TA is recommended for BTNs. "Conformal ablation" refers to a technique in which the ablation is carefully shaped or tailored to match the specific contours of the targeted BTNs[114-116]. This approach aims to precisely treat the BTNs while minimizing damage to the surrounding thyroid tissues.

TA is considered complete once the heterogeneous hyperechoic area covers the target BTNs. CEUS is recommended for

evaluating the immediate effectiveness of TA[16,117–119]. Complete ablation is achieved when the nonenhanced ablation zone completely covers the target BTN, and additional TA should be performed immediately if any enhancement is detected in the target BTN. If CEUS is not available, B-mode ultrasound, CDFI, or MFI can be used to assess the effectiveness of TA[16,119]. High-frequency ultrasound is recommended for evaluating RLN function during and after TA[81,82,120].

TA should be terminated immediately if the patient experiences intolerance due to severe pain, breathing difficulty, or other serious complications that may be life-threatening. After the procedure, the patient should be observed for at least 30 minutes with continuous monitoring of peripheral oxygen saturation, electrocardiogram, or noninvasive blood pressure.

Recommendation 14: Ultrasound examination should be performed before TA to develop the procedure plan, including identifying the target BTNs and determining the sequence of the TA for multiple BTNs (Strong recommendation, high-quality evidence).

Recommendation 15: Local anesthesia of the skin and thyroid capsule is recommended before TA (Strong recommendation, high-quality evidence).

Recommendation 16: TA for BTNs should be performed methodically and sequentially, beginning from the deeper part of the BTNs and gradually moving toward the superficial part (Strong recommendation, moderate-quality evidence).

Recommendation 17: For bilateral BTNs, the BTNs on the safer side (far from the RLN) should be ablated first, and RLN function should be confirmed to be normal before proceeding to the contralateral BTNs (Strong recommendation, moderate-quality evidence).

Recommendation 18: Hydrodissection based on perithyroidal fascial spaces is a key factor to ensure the safety of TA and should be performed in all cases (Strong recommendation, moderate-quality evidence).

Recommendation 19: A conformal TA is recommended for BTNs (Strong recommendation, moderate-quality evidence).

Recommendation 20: B-mode US, CDFI, CEUS, or MFI is recommended for evaluating the effectiveness of TA depending on the operator's preference and available resources (Strong recommendation, moderate-quality evidence).

Recommendation 21: High-frequency ultrasound is recommended for evaluating RLN function during and after TA (Strong recommendation, high-quality evidence).

Postablation management

Follow-up duration

Postablation follow-up is generally scheduled at 1–3, 6, and 12 months after TA and then annually thereafter.

Follow-up examinations

1. Conventional ultrasound is effective for monitoring changes in the size of the ablation zone in most cases. Residual lesions/local recurrence around the ablation zone typically appear as increased vascularity on CDFI. When necessary, CEUS or MFI can be used to further confirm the diagnosis. Repeat TA is recommended for confirmed residual lesions/local recurrence, especially in patients with persistent clinical symptoms[93,94].

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International Journal of Surgery

2. At least one time of thyroid function examination is required within 12-month follow-up period due to the possibility of thyroid dysfunction[121,122]. Patients with long-term thyroid dysfunction are recommended to consult with endocrinologists.

Recommendation 22: Patients with BTNs after TA should receive regular follow-up with ultrasound and/or thyroid function examinations (1, 6, and 12 months after TA and then annually thereafter) (Strong recommendation, moderate-quality evidence).

Effectiveness

TA has been identified as an effective and safe treatment for BTNs, with extensive evidence from randomized controlled clinical trials, cohort studies, and case series (Supplemental Digital Content Table 1, available at: http://links.lww.com/JS9/G707). Various indicators are used to measure the efficacy of TA for BTNs.

Complete ablation is one of the efficacy indicators of TA for BTN. A VRR ≥50% within 12 months after TA is considered another indicator of successful treatment [36,57,87,123-125]. Additionally, TA can effectively alleviate BTN-related symptoms and improve patients' quality of life [17,19,38,57,126-128]. Thus, in the present consensus, the therapeutic effectiveness of TA for BTNs was assessed in three dimensions: complete ablation, VRR, and BTN-related symptoms. A successful TA should meet one of the following criteria: ⃗② complete ABlation; ⃗② VRR ≥50%; and ⃗③ BTN-related symptoms either disappeared or were significantly alleviated (strong recommendation, high-quality evidence).

Recommendation 23: Evaluating the efficacy of BTNs after TA from three dimensions is recommended. A successful TA of BTNs should meet one of the following criteria: $\odot$ complete ablation; $\odot$ VRR $\ge 50\%$; and $\odot$ BTN-related symptoms either disappeared or were significantly alleviated (Strong recommendation, high-quality evidence).

Complications

TA is a safe treatment option for BTNs with a low risk of complications. According to the literature[129-132], major complications include nerve damage (RLN, branchial plexus, sympathetic ganglion, cranial nerves, vagus nerve, external laryngeal nerve), tracheal/esophageal injury, TNR, and permanent thyroid dysfunction, etc.; minor complications include hemorrhage, skin burns, and transient thyroid dysfunction, etc.; and side effects include fever, pain, edema, bruising, nausea and vomiting, vasovagal reactions, and cough, etc. To facilitate clinical management, complications are also classified based on the time of onset: periprocedural (during TA and within 24 hours after TA), short-term (within 30 days after TA), and long-term (more than 30 days after TA). Generally, periprocedural complications include hemorrhage, nerve damage, skin burns, tracheal/oesophageal injury, etc., and short-term complications include TNR and transient thyroid dysfunction, etc. Long-term complications include permanent thyroid dysfunction, etc.

RLN injury

RLN injury is a major complication, with an incidence of 0.94%–5.1%[113,129–131,133]. Most RLN injuries are transient

and resolve/alleviate within 3-6 months. Permanent RLN injury is rare, with an incidence of 0%-0.7%[131]. Patients should be informed of possible symptoms of RLN injury, such as voice change, hoarseness, aspiration, throat discomfort, and even breathing difficulty.

Hydrodissection based on perithyroidal fascial spaces is crucial for preventing RLN injury in the TA, and controlling the ablation power near the RLN is also important [54,55,111-113]. It is challenging to perform a safe TA in cases of RLN variations, for example, nonrecurrent laryngeal nerve and RLN variations caused by Zuckerkand tubercle [134-136].

Ultrasound is recommended for evaluating RLN function during the TA procedure[81,82]. Laryngoscopy is advised for some male or elderly patients when the vocal fold is not visible via ultrasound. Neurotrophic drugs can be helpful in the treatment of RLN injury. Several studies have reported that immediate injection of a cold isolation liquid into the area of the involved nerve may be beneficial[137,138]. Voice training can be considered as an adjuvant therapy to improve voice quality[139]. Generally, dysphagia, throat discomfort, or aspiration during swallowing may resolve within several days to a few weeks without specific intervention.

Thyroid nodule rupture

TNR is a relatively rare but major complication, with an incidence ranging from 0.2 to 2.0%[130,140-143]. TNR typically presents with local symptoms such as persistent and worsening neck distending pain, tenderness, skin redness, swelling, increased skin temperature, restricted neck movement, and dysphagia and may also involve systemic signs such as fever. When these symptoms occur, patients should be educated to seek prompt medical attention.

Ultrasound examination is recommended for patients with suspicious TNR. Liquefied necrotic nodules appear as heterogeneous hypoechoic areas that disrupt the thyroid capsule and extend into the extrathyroidal spaces, accompanied by surrounding soft tissue swelling. Occasionally, a hypoechoic area exhibits a sense of dynamic fluid flow during respiration or with probe compression. A CT scan is recommended for patients with severe symptoms, such as dyspnea and dysphagia, or for whom the suspicious lesion is retrosternal or in the mediastinum[141,143,144].

Compared with small BTNs, larger BTNs are associated with a greater risk of TNR after TA, and local violent pressure on the operation area may play an important role in inducing TNR[103]. Therefore, it is important to educate patients to avoid local mechanical pressure on the BTNs after TA, especially for those with large BTNs[103,141,143,144]. Additionally, several studies found that excessive ablation energy can increase the risk of TNR[140,141,143].

According to the literature, most patients with TNR after TA can recover without surgical intervention, conservative management is often effective for TNR[140,141,144]. Nonsteroidal anti-inflammatory drugs can help alleviate pain and inflammation. It is also essential to avoid vigorous neck movements and external compression of the lesion site to alleviate symptoms and prevent the progression of TNR[103]. Ultrasound-guided aspiration could be recommended for TNRs with severe symptoms and liquefied necrotic material on ultrasound[141].

Cao et al. International Journal of Surgery (2026)

Hemorrhage

Hemorrhage is the most common minor complication of TA for BNTs, with an incidence ranging from 1.02% to 17.0%[129-131,133]. Hemorrhage can cause neck distension and pain, and severe hemorrhage can lead to airway obstruction or even asphyxia.

Careful puncture under real-time US guidance and CDFI is helpful for avoiding hemorrhage. Compressing the neck for 30 minutes is suggested to reduce delayed hemorrhage after TA. Hemostatic drugs, such as tranexamic acid or hemocoagulase Bothrops Atrox[145], can be used to control active hemorrhage or can be administered prophylactically before ablation in patients at increased risk of hemorrhage.

Local compression could be applied for a mild hemorrhage. TA is recommended for active hemorrhage[146-148], particularly when the bleeding vessel can be identified with CEUS or CDFI. Patients should be advised to seek prompt medical attention if they experience persistent or worsening neck pain, swelling, or any signs of breathing difficulty. Although severe dyspnea or death caused by hemorrhage in the TA for BTNs is rare[149], emergency equipment and training on bedside evacuation of neck hematoma, intubation, and cricothyroidotomy are essential.

Rare complications

A few rare complications have been reported in previous studies, including skin burn, trachea necrosis[150,151], Horner syndrome[152], brachial plexus injury[130], vagus nerve injury[153], and external laryngeal nerve injury[154]. Most of them are related to unexpected thermal injury to perithyroidal structures or anatomical variation. Sufficient hydrodissection and thermal field management are important for avoiding the above complications[54,55,111–113,155]. Short-term thyroid function changes may occur after TA for nonfunctional BTNs, but permanent dysfunction is rare[121,122,130,156].

Recommendation 24: Hydrodissection and ablation power control should be employed to reduce the risk of RLN injury (Strong recommendation, moderate-quality evidence).

Recommendation 25: ① In cases of active hemorrhage, TA is recommended for hemostasis, and ② for mild hemorrhage, hemostatic drugs and local compression are recommended for hemostasis (Strong recommendation, moderate-quality evidence).

Recommendation 26: To avoid TNR, a rare but major complication, patients should be educated to avoid local mechanical pressure on the BTN after TA, especially for patients with large BTNs (Moderate recommendation, moderate-quality evidence).

Conclusions

The present consensus outlines 26 recommendations for TA in the management of BTNs, which are beneficial to enhance the accessibility, safety, and standardization of TA for BTNs and promote its global development.

However, during the development of the current consensus, several issues should be considered. First, the expert panel has a geographic imbalance, with a relatively high proportion of experts from Asia. This may be due to the broader application of TA for thyroid nodules in Asia and the greater number of studies from Asia in recent years. Second, owing to limited

high-quality evidence, a few recommendations are based primarily on expert experience and retrospective data. Conducting high-quality studies, such as well-designed prospective studies, intercontinental studies, and multiethnic studies, is crucial for strengthening the evidence base behind the consensus. This consensus may be updated within 5–10 years based on further clinical experience and high-quality research, which will further enhance the importance and role of TA in the management of BTNs.

Ethical approval

Ethical approval was not needed for this study, as it did not involve human participants or animals.

Consent

Informed written consent was not needed, as no human participants were involved. Consent for publication was waived because all medical images used in the manuscript were published anonymously.

Sources of funding

This study was supported by a grant from the National High Level Hospital Clinical Research Funding (Grant No. 2025-NHLHCRF-JBGS-A-WZ-01) and the National Natural Science Foundation of China (Grant No. 62176268).

Author contributions

S.-L.C.: contributed to the original draft writing and was responsible for data curation. M.-a.Y., S.-R.W., S.-Y.Y., G.D., B.C., J.-Q.G., B.-Q.F., and J.-W.T.: contributed to investigation. S.-L.C., B.-Q.F., Z.-B.C., K.-L.C., G.D., H.A.G., G.A., T.S., J.-F.H., and J.-Q.G. contributed to resources. S.L.C.: and S.R.W.: contributed to the methodology, formal analysis, and validation. M.-a.Y. contributed to the conceptualization, project administration, supervision, and funding acquisition. S.-R.W., J.-H.K., G.W.R., S.Y.-Y., G.M., W.-C.L., G.D., K.-L.C., B.C., S.-S.W., I.J., H.A.G., J.-Q.G., G.A., C.N.L., J.-F.H., R.D.C., E.S., B.-Q.F., F.W., J.L.D.C.R., Z.-B.C., T.S., Ö.K., J.-W.T., G.G., N.B.M., N.S.T., P.P., M.D., and M.A. Y. participated in reviewing and editing the manuscript. All authors reviewed and approved the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Research registration unique identifying number (UIN)

Not applicable.

Cao et al. International Journal of Surgery (2026)

International Journal of Surgery

Guarantor

Ming-an Yu.

Provenance and peer review

Not commissioned, externally peer reviewed.

Data availability statement

Not applicable.

Acknowledgements

Not applicable.

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