CINXE.COM

Just a moment...

<!DOCTYPE html><html lang="en-US"><head><title>Just a moment...</title><meta http-equiv="Content-Type" content="text/html; charset=UTF-8"><meta http-equiv="X-UA-Compatible" content="IE=Edge"><meta name="robots" content="noindex,nofollow"><meta name="viewport" content="width=device-width,initial-scale=1"><style>*{box-sizing:border-box;margin:0;padding:0}html{line-height:1.15;-webkit-text-size-adjust:100%;color:#313131;font-family:system-ui,-apple-system,BlinkMacSystemFont,Segoe UI,Roboto,Helvetica Neue,Arial,Noto Sans,sans-serif,Apple Color Emoji,Segoe UI Emoji,Segoe UI Symbol,Noto Color Emoji}body{display:flex;flex-direction:column;height:100vh;min-height:100vh}.main-content{margin:8rem auto;max-width:60rem;padding-left:1.5rem}@media (width <= 720px){.main-content{margin-top:4rem}}.h2{font-size:1.5rem;font-weight:500;line-height:2.25rem}@media (width <= 720px){.h2{font-size:1.25rem;line-height:1.5rem}}#challenge-error-text{background-image:url(data:image/svg+xml;base64,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);background-repeat:no-repeat;background-size:contain;padding-left:34px}@media (prefers-color-scheme:dark){body{background-color:#222;color:#d9d9d9}}</style><meta http-equiv="refresh" content="390"></head><body class="no-js"><div class="main-wrapper" role="main"><div class="main-content"><noscript><div class="h2"><span id="challenge-error-text">Enable JavaScript and cookies to continue</span></div></noscript></div></div><script>(function(){window._cf_chl_opt={cvId: '3',cZone: "jamanetwork.com",cType: 'managed',cRay: '917b9faffb0e4d96',cH: '0kEZ35h8WftkRkatJ2qPU.daO1jscY3XISgbkYO0kVk-1740527700-1.2.1.1-S2NMF9grFQkZ9hQWdWGNlTs1nAvmIWv.TKK7IrBg96fJG6Ta9AJa8Bc._jJL9cmO',cUPMDTk: "\/journals\/jamasurgery\/articlepdf\/2813494\/jamasurgery_hashimoto_2024_gm_230006_1711661306.13439.pdf?__cf_chl_tk=.VIubndiBCCPP0syUhBeAashovwsTDzUaPaP87UOX.c-1740527700-1.0.1.1-Tiq_6YZkszLtmQia7cwZlGqe_dulC9UbHdUz9mQy_H0",cFPWv: 'b',cITimeS: '1740527700',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/journals\/jamasurgery\/articlepdf\/2813494\/jamasurgery_hashimoto_2024_gm_230006_1711661306.13439.pdf?__cf_chl_f_tk=.VIubndiBCCPP0syUhBeAashovwsTDzUaPaP87UOX.c-1740527700-1.0.1.1-Tiq_6YZkszLtmQia7cwZlGqe_dulC9UbHdUz9mQy_H0",md: "MPRbH1lVbsshtRNguzyDmoneCAcmszOt1Gaan08xgYE-1740527700-1.2.1.1-B9UOsbeA4TBY4gRqFxRLMxF6gDg7w15sC8d79X.CH6RVsViSpz4LsxsQ88LFXtj0Y2X3_0JUmwF.xW3FkehsQdPXwLFzA7qsW02itwrz7Kr4CbswWAJHu7SPOGE7._5cSrBEjASHmOA5kJe0NHGfvZFAX_ZqzG17dOwiVFoHO3EwV9xg_tIyEWBUFLMbophfX.QNv38LeWdbYWT_SqT9cJ6km6FmCsXx5F1AAYA1sCO21NkJgM9FNfKkadYGVGETkjyQ28S6.CB2OGwdJZTX9gJPS_hRGAd3pITS8_DkAAfZWLjS5GOzBss1PiPpbl_nA.PhWiskAOUKHBEFPR1IyCEjQjIPZ.z2GAPE20mD4WURuPzxxxbh_IxcTiuncunjQ_1bRsY8g1QUSJynwkcnxjRXutJg2EvxzU89NBEHdRjG47N7JTq7rDG52T.7D_gu03r9W4Tqfl1FC9QiYcaLxdseqPvfH7Ek5PwtQSqFOEWomA.uuddVrAc9MwwuVuM8X.Sop7omyq1uxvwBxewhij26nP9XdutcNfMuviNSc0QkQfDtAW6p3Ur35DTuvomwAqjdS5ByFVBjCLSM4h.mzyzrJ858M99SHBwLmIzNZrtNEkKkL3jhqbFecZZJ6sLEglFwZ_.IRjk9kevccTinmgLCkmrUYk4eNdCmtNFPqjJhvwMnf9Eejkq.tp45aswuYV78lAyrmkK9g9LhP3pcKMFgkL081t7IDAtZNOsVv0afJU3iqV3Nf684YZTOUjBs.UZelRvwBbOXTIy40bpOMgxafH0JFMFJQQgaTG6bNcek97qJ8F9Mu_zheXWL03gLySjkimfHjg3FxYBZA7ejJiyzxMvtpAUM_aWpAGKUz6VfaDMLev2hPa6Xyi2o4A9XILZ3VBvs6bBRI9e1pUO.7Vq5ewYENlLRCl.qUP1KI2hTlHVxbrAWIvNSFeuprdfQZIIlKgunA92R.88WY.VHfee0zG5x7ZyCky3oPT7OaNF8jMB1erJbd9p8k.hyvT2TWm9wbwvaAWXldco0mLPv4Cb.gdOVs55uAYiFKUpB0u698Y4JhpsvaCSEl9c4lkbxmnTzdKCHWwf6SE5t.lFt3QNrEpVNlcZUMdsEcqhzZ8INNTlz_Ei.Fz_nCXeMR1POsI3TV73hCPuBbYicbVsnaLUTPi71OUQq4iyuuoTe5VZEGdg4Je7ZfbIbjeGcf.xwqT8WuihRzBBGmNK6gIrfEmWtZdHXWmvlVSiqriysXoqaRp7aKWnsuIKetsS14oxHsjwHnQb4GwNJpXWCcCGjbozylLpCy03gCcXA1GBmB.j269u.SdHgsSKtRqdtCAAOvGQ3BUxDimNniIB6qIEzkSiaZWIfk7gpaKSpnQ2Yjw0kaiiekdUPi1LswkAxLHcqQ7ftp31CycWlmGjAJWmaoAtNjZ1buibQ8_PPhI96LPCFQQEeig_yigXku5vUYXBJaI5Qo5WHy8kfradDsc3I9u97i_n4yXsdc3pDv5hS5JlYFk1fPoaRt6sXFXb5tHnsPCs4KmJ2D4Q8BjhO9ef7I98uiw0J3xjGe8Urs1x1MQGNRai49erJLoJ5EQ8Baq9v_X3w4mSxgML5sE0OUw.ivs9K4XJmkgPKpa0QWIQWv5t68AIaAp77eJ1q5BY6KmHLNv6XBlqbELFVbBHhK0Mh33V0zKUSBCjG.uTrZQvRCYZyGQk0revqM0WLdw1TBu_sAxvfbaVXClO9qCPgpBZVIjtiygKCzNS7slJWwjggKEg8USc6DLc6RABdPzwvtzlfxiX9sQya47Y9Fm98PDrEwsqXkSlO3ovt6RKbeVS5E4cqaOscBDuSHfxWDn_O_wPcW9.D_xmrw6jFTwR6gTZtzJJwVmOeqIrokOMwQBhaexL9OeZxtUq2AWWh44PjQMyNdgukojNn2jKhYLMgQW5wjOgxzAdy6FqYYI35ryRk4lIwgvU1szuhz9ROnEihVj9JyUHqnVT34.JducK1zkpKoL73i4t0epw1FyVQ5R40RBlUAc2ytn5UZSgg5nxyugqNso68uJv8mbYYreoKdMDqi_zkmHSZhRaPTh5IKxFA35CxYFVNna2WIKUtsuaN7_rITHZrz7IE31FC0ExIl6T__XSwHCxxoen.pZptM2iiuGNYQ.jaM5GL3pF8gOa0DKy2R5RR1eL8jtRmk3_Wl.9BdKpQu8.wLAI5OB167LF6k7IVamso8LEdP_3D696x22NAW4.MDieEEmae7zpDHao_dTZzx7wOV1ehZdR7QaS1nNmEvd1yx2pG_tPt_XwYPbZq7khij46LG.BTjqclPl9Y_BOvsbUZm6WaTibLiBvrTKzIP6CLKxzkzj9FmDLLBNyafVmSvYhNTM9zrTq96nySq5ygmzR39OFBWEygsRGp7.jxEaLv1mSRPuVSq.6ne2V2JS5abf43uI1SQq5GfSVEl9wwhJi2LIn_FmFY6ti3iZAeESdti3nrWeqP51Qe9a4tHKmyMvHTYty5PVQ3P1HGcGcVZhCQVG0NsDrBLiQHnIC41RdzGbJipifo3xoUbUX9Vdt1Co4fERCK2afKDNNBhJr8vKyJv7nYiF9TEMXI1bSZ3ugkWK3Lk_JuP3Qm42MPog6I1pm9AOuBvg_BkthMbIkL41gjrt_0_3Um41HGU6pyThD73m5l3pE5_7l8FLE0Iw3RifEWEQY_59SEvkaPciqxkBEz81z.m5GVLl8OIq919hwq1IVpDDz8BwULZOzvrcSR875JQvMHzadoRyy0Qg",mdrd: "P3LBV5albgJ1RT5s8WKhcaLOH0pBz8rffMVfWkyaSBc-1740527700-1.2.1.1-PcRmAYlAciBel3FccKOTprYP0NL_F1P_V3dzi73PUNtLvpmY4AK.ixhPzyGb_549B1aRXfhFivNfusBmz3g4LTYfDl6rdNj0miU6E02b5o6_Y2qieshdvBkTX95NGC7HD7d7f.T6ZZ_APJ9ySRDYD0eQzOAuThp.vO6dMdXkhuTg05KShLTm.g9.Q.Av1QLIX1S0U5lSanLEwopfY6_ML3F8u7.cL6sGSZ6YNKdjDsTSfla0TmW9yzqu63bZ_6dKQDudq82me4aukFu_jkjrzZWJKtJpjmADZMCV45YXoL1jXgOy9QrbxqEajScUzceNL0KqJ3OEgZneCV40X.CCNdORGj6xiLmAcAAycl0mcMfEx.4TeESmASmelrpEbpSNOGROjr3ZQgsjt8cXv81axWFKHCiCtuJLsQJr6y69_5N8xkR5sWypDYSuQP04afQUWR9rlbdFTF9mlbEHFpT9_MyahSb3Q139y7wbzd.v_ixyArQKjsOpxVH9IADMHJvTjUbfbq0FAgxvOsgEz2.8DdvJrlkPO3XFFzl9Ssj.woeSC_eYiAcIjdjkW676yQ4GyEkUix.MO2ecVzODG3xV2XB5MoITllU4pBZZ4KBXEGONHFROv.kAqZ9t3LpXuR89WaXuRe5FuNv8tr3JU5boTphmCilLm_bU2zd4JpOMJC1umuKh7SSwhcfAU1.kVIGUW_YOcwVJnJILjaOqt814taqXfkcrTvvUiKexGbWe9YXt0i1s8BMP7RdBygnlTxYyOplGOA7wt096WqI2YTwO2lpPhL6K1GZDE3_uIavfNerq335T.6V.J93XnjAtpWVgjZ8ZL_QjILygFamIfi7gjCVR03hKyCX4kLxuBOZ2l35aVUim7F6j0zeAajXvpwN2.4UT_Dq6JgiT9rmzVU5.J79.mYxcX85JNvEWmeqEei1bLVU4q5pxCMY985ylzMmnGIbdqDkMXme8fb1yjsjERDcID9tEzKO6fCQb1n8AC4o1tD7Ndv7EbCGuEeHQWdm7v.YEweW.4McIULIFS8KKnBfWrDEXDn3T.9A5GCI8ZeNZUGCE7N9yep0SOI.PoWE.PnmwQZ0nI3cVVPd1CmRXwdKsqNJ7O5h4SFkrmu_aFshr7d9euRjLdAj5YE2W_PzG.NIkn1g2B0sXNcpk2PIjmK9xrd0vg.JyHmTSuDUMzcKjuxXYd4OOCeoJo3RXXHV4ckPTPOm_T9huTgpV2GM_Hfmcuf2RMRo5dGaobwwq47gnIhISYovLLFUOgs5MdQnKlIMcmnsvE3Aiey7_ftgrXvW0QBXIUzYpGAyYUx2IJKSpHJkB5gUQ5xA67EcifH2vC0AzBibp.KoISspuMZ5JXobVW5S3MGbAHfXOb7ocO7SV3MUfw8Odq_ZiO4EsHFjD0nTbbtnRA9iYvgGEO1Jal3fNNCN2Hd4CL1CV_2V1_5MyblpgAVJSzH.Fz.dhR2Kpd6616kfiDr24f7RQ1SMIrT11lV41iuo6JQs7OKcCRZRp4Osa93VmKFkUy_LTn2bGQNmeR8pc1Vpk6Q27qy2l3XEB0uGXMIE8LLUe28Cz6CjD4nfX4G49SUsCrXLrgNVI8LuZftyrn68lZzKiOmCxGqhG1IjKhju3CU1foCd7OBYmkMCHH6pe6EjKJ3IBSprOwi4TyKbHOZchxPXnghAGB09SCWUo2Epi58xombz86OqcZwkLSYGMyPyKaBvLFJqaxH18ZRrtsAtj5Z6XdSW7IpfIGplu5vhMcbhSH6sPamA.MFS4YDGKmDJodwhgaNCdeRR.cs17LAczffSxPjHPw_I_wOjEeCtn5M6eC3jqPN0lyKkq__Z0IoR3QzBUO0MBRqEsv.Nr_gYOnZbAFiezf0AzcFriWx3tkEmtrHzjBeK0ClYFJJzJqmidq1jJvtI3XQkpNQmhZ4GMmLMH5nHLAYCMmCJSS_Kkk7ZFdz00OSPMApA10GBTfAsLfz7jkJkz"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/b/orchestrate/chl_page/v1?ray=917b9faffb0e4d96';window._cf_chl_opt.cOgUHash = location.hash === '' && location.href.indexOf('#') !== -1 ? '#' : location.hash;window._cf_chl_opt.cOgUQuery = location.search === '' && location.href.slice(0, location.href.length - window._cf_chl_opt.cOgUHash.length).indexOf('?') !== -1 ? '?' : location.search;if (window.history && window.history.replaceState) {var ogU = location.pathname + window._cf_chl_opt.cOgUQuery + window._cf_chl_opt.cOgUHash;history.replaceState(null, null, "\/journals\/jamasurgery\/articlepdf\/2813494\/jamasurgery_hashimoto_2024_gm_230006_1711661306.13439.pdf?__cf_chl_rt_tk=.VIubndiBCCPP0syUhBeAashovwsTDzUaPaP87UOX.c-1740527700-1.0.1.1-Tiq_6YZkszLtmQia7cwZlGqe_dulC9UbHdUz9mQy_H0" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>