Thyroid surgery has evolved and one of the biggest advances has been the introduction of the Harmonic Scalpel (Ethicon Endosurgery, Johnson & Johnson).
The Harmonic Scalpel uses ultracision technology originally developed in the United States to assist gynaecological surgery.
The Harmonic Scalpel device utilises a piezo-electric crystal to turn electricity into motion at the tip of the active blade which vibrates at 55,000 Hz. This rapid motion causes tissue between the blades - including blood vessels to be sealed and then divided in a few seconds.
The advantages of this technology are compared to standard techniques of electric cautery devices (diathermy) and are:
1. Reduced bleeding
2. Less heat in the tissues - potentially heat can be damaging to surrounding structures
3. Avoidance of electricity passing through the patient
As a result of these advantages as a thyroid surgeon I find:
1. Less bleeding means greater vison of delicate structures in the neck
2. Easier to protect the recurrent laryngeal nerve
3. Easier to preserve the parathyroid glands
4. Much faster as I can divide structures very rapidly
All of this hopefully translates into a better outcome for a patient undergoing thyroid surgery. There are a number of studies now available including some randomised controlled trials comparing thryoid surgery with and without use of the Harmonic Scalpel which clear show these benefits.
If you would like to watch a video of me undertaking thyroid surgery with the Harmonic Focus device please click on the link below.
Mr Mclaren performing thyroid surgery with Harmonic Focus device
Thyroid and Minimal Access Thyroid Surgery
Thursday, 6 October 2011
Wednesday, 31 August 2011
FHH - Familial Hypocalciuric Hypercalcaemia
FHH
This is an interesting topic for anyone with parathyroid disease.
The interest in FHH comes from the fact that it is one of the causes of an elevated calcium level so should be considered by your doctor as part of the differential diagnosis.
The important point about it is that the parathyroid glands are normal... The elevated calcium of FHH does not for reasons that are unclear cause symptoms in the way that a similar level from parathyroid disease would. There is no cure for FHH and the elevated calcium is permanent and not in any way a problem.
If the diagnosis of FHH is missed and you end up having surgery nothing abnormal will found the surgery will achieve precisely nothing.
FHH is excluded by checking a 24 hour urine collection and measuring the amount of calcium excreted in the urine. This is a very important test.
FHH patients have a low level of urine calcium excretion - usually <100mg per 24 hours.
Other hints that this condition is present are:
1. Only mild elevation of calcium which has been stable over time
2. Young age
3. Patients with a family history of 'parathyroid disease'
Nowadays if there is doubt there is a genetic test to exclude FHH however this takes a long time to get done and in my view is generally not necessary.
www.bucksendocrine.com - Parathyroid and minimal access surgery by a UK specialist surgeon
Facebook Discussion Page on Parathyroid Disease
This is an interesting topic for anyone with parathyroid disease.
The interest in FHH comes from the fact that it is one of the causes of an elevated calcium level so should be considered by your doctor as part of the differential diagnosis.
The important point about it is that the parathyroid glands are normal... The elevated calcium of FHH does not for reasons that are unclear cause symptoms in the way that a similar level from parathyroid disease would. There is no cure for FHH and the elevated calcium is permanent and not in any way a problem.
If the diagnosis of FHH is missed and you end up having surgery nothing abnormal will found the surgery will achieve precisely nothing.
FHH is excluded by checking a 24 hour urine collection and measuring the amount of calcium excreted in the urine. This is a very important test.
FHH patients have a low level of urine calcium excretion - usually <100mg per 24 hours.
Other hints that this condition is present are:
1. Only mild elevation of calcium which has been stable over time
2. Young age
3. Patients with a family history of 'parathyroid disease'
Nowadays if there is doubt there is a genetic test to exclude FHH however this takes a long time to get done and in my view is generally not necessary.
www.bucksendocrine.com - Parathyroid and minimal access surgery by a UK specialist surgeon
Facebook Discussion Page on Parathyroid Disease
Sunday, 7 August 2011
Thyroid Operations - How many should a surgeon undertake per year?
There has long been a debate in the medical community about how many operations a surgeon should do each year.
Thyroid surgery is rapidly becoming a specialist operation - this is a good thing as data from the British Association of Endocrine and Thyroid surgeons has clearly demonstrated that outcomes are better from surgeons undertaking greater numbers of thyroid operations.
In particular - length of stay in hospital and risk of needing calcium tablets after surgery are both reduced.
The British Association held a landmark vote last year which said that surgeons should perform more than 25 thyroid operations a year in order to maintain skills and be considered for revalidation (relicensing) in the future.
There are however considerable numbers of surgeons in the UK who are not members of the Association and undertake few operations.
Your surgeon should be able to tell you:
1. How many operations they perform a year on thyroids
2. Figures relating to risk of hypocalcaemia post thyroidectomy (the best will be around 5-10%)
3. Risk of injury to the recurrent laryngeal nerve in their hands
4. Average length of stay and number of daycase operations they perform
Daycase surgery is a good marker in my view as if a patient is fit, alert, pain free and keen to leave the same day it is a good indicator of a successful operation. If surgeons are unable to achieve discharge on the same day you should question why not.
www.thyroidsurgeon.org.uk
www.bucksendocrine.com
Thyroid surgery is rapidly becoming a specialist operation - this is a good thing as data from the British Association of Endocrine and Thyroid surgeons has clearly demonstrated that outcomes are better from surgeons undertaking greater numbers of thyroid operations.
In particular - length of stay in hospital and risk of needing calcium tablets after surgery are both reduced.
The British Association held a landmark vote last year which said that surgeons should perform more than 25 thyroid operations a year in order to maintain skills and be considered for revalidation (relicensing) in the future.
There are however considerable numbers of surgeons in the UK who are not members of the Association and undertake few operations.
Your surgeon should be able to tell you:
1. How many operations they perform a year on thyroids
2. Figures relating to risk of hypocalcaemia post thyroidectomy (the best will be around 5-10%)
3. Risk of injury to the recurrent laryngeal nerve in their hands
4. Average length of stay and number of daycase operations they perform
Daycase surgery is a good marker in my view as if a patient is fit, alert, pain free and keen to leave the same day it is a good indicator of a successful operation. If surgeons are unable to achieve discharge on the same day you should question why not.
www.thyroidsurgeon.org.uk
www.bucksendocrine.com
Thursday, 4 August 2011
Thyroid Nodules
Thyroid nodules (lumps) are very common.
Approximately 50% of people will have a thyroid lump if the thyroid is scanned with an ultrasound machine
In the UK the only lumps that need to be assessed are:
1. Visible thyroid swellings
2. Palpable thyroid swellings
3. Thyroid nodules seen on scans >1cm in size
Thyroid nodules under 1cm in size do not require any action
In my view thyroid ultrasound is over used particularly outside hospitals and I generally recommend that patients should first see someone in a one-stop thyroid clinic where biopsies are undertaken after clinical assessment.
The only way to determine whether a thyroid nodule is benign or malignant is to perform a fine needle aspiration of some cells which are then assessed under a microscope by a cytology specialist.
The Fine Needle Aspiration (FNA) can either be done by the consultant in clinic - quick and straightforward using a blood test needle - or done by a radiology specialist with the aid of ultrasound.
The results from FNA are classified:
THY 1 Not enough cells to give a clear diagnosis - the test must be repeated to acheive a diagnosis
THY 2 Benign - repeated at 2-3 months as a second double check and if still benign
THY 3 Indeterminate - this should be reviewed in a thyroid multi-disciplinary team meeting
THY 4 Suspicious result which may represent a thyroid cancer
THY 5 Definite thyroid cancer according to cytology
The action following the biopsy is outlined below:
THY 1 Repeat to establish diagnosis if possible - if no clear answer needs surgery to remove
THY 2 Benign and can therefore safely leave alone or offer patient choice re excision
THY 3 Remove to acheive definite diagnosis as 20% plus are cancerous
THY 4 Repeat to acheive definite diagnosis if possible or remove with on-table frozen section
THY 5 Needs surgery - usually a total thyroidectomy
Benign nodules are still removed. The reasons for removing these are:
1. Symptoms - often uncomfortable in the neck, difficulty swallowing, choking feeling etc
2. Cosmetic issues
3. Cancer concerns
4. Family history of thyroid cancer
5. Radiation exposure - particularly as a child (increase cancer risk)
Bucksendocrine.com - Thyroid surgery by a UK specialist surgeon
Thyroid Surgery by a UK specialist surgeon
Approximately 50% of people will have a thyroid lump if the thyroid is scanned with an ultrasound machine
In the UK the only lumps that need to be assessed are:
1. Visible thyroid swellings
2. Palpable thyroid swellings
3. Thyroid nodules seen on scans >1cm in size
Thyroid nodules under 1cm in size do not require any action
In my view thyroid ultrasound is over used particularly outside hospitals and I generally recommend that patients should first see someone in a one-stop thyroid clinic where biopsies are undertaken after clinical assessment.
The only way to determine whether a thyroid nodule is benign or malignant is to perform a fine needle aspiration of some cells which are then assessed under a microscope by a cytology specialist.
The Fine Needle Aspiration (FNA) can either be done by the consultant in clinic - quick and straightforward using a blood test needle - or done by a radiology specialist with the aid of ultrasound.
The results from FNA are classified:
THY 1 Not enough cells to give a clear diagnosis - the test must be repeated to acheive a diagnosis
THY 2 Benign - repeated at 2-3 months as a second double check and if still benign
THY 3 Indeterminate - this should be reviewed in a thyroid multi-disciplinary team meeting
THY 4 Suspicious result which may represent a thyroid cancer
THY 5 Definite thyroid cancer according to cytology
The action following the biopsy is outlined below:
THY 1 Repeat to establish diagnosis if possible - if no clear answer needs surgery to remove
THY 2 Benign and can therefore safely leave alone or offer patient choice re excision
THY 3 Remove to acheive definite diagnosis as 20% plus are cancerous
THY 4 Repeat to acheive definite diagnosis if possible or remove with on-table frozen section
THY 5 Needs surgery - usually a total thyroidectomy
Benign nodules are still removed. The reasons for removing these are:
1. Symptoms - often uncomfortable in the neck, difficulty swallowing, choking feeling etc
2. Cosmetic issues
3. Cancer concerns
4. Family history of thyroid cancer
5. Radiation exposure - particularly as a child (increase cancer risk)
Bucksendocrine.com - Thyroid surgery by a UK specialist surgeon
Thyroid Surgery by a UK specialist surgeon
Thursday, 7 July 2011
Parathyroid Errors
I often see patients from across the UK and a number from overseas - the record distance travelled was from Sydney, Australia!
There seems to be a common theme from these patients usually resulting in delays in diagnosis and generally getting sorted out. I thought it might be helpful to list some of the issues:
1. Calcium only slightly elevated
As a result of only tiny elevations in calcium it is often said that there is not a problem. This is incorrect. Calcium levels should be in the normal range - if not you need to work out why not and only then can a decision be made as to what to do.
2. PTH level normal
PTH levels should be almost zero if the calcium is high as the glands are supposed to switch off and stop making PTH. If PTH levels are normal we term this 'inappropriately elevated' and it suggests primary parathyroid disease.
3. Mildly elevated calcium and parathyroid disease is OK
No it is not. Calcium levels and indeed parathyroid hormone levels are completely unrelated to symptoms so some patients have terrible symptoms even with mildly elevated calcium.
Calcium levels do not make a difference to osteoporosis. So if you have the disease you can develop osteoporosis and it makes no difference how high the calcium level is
4. Surgery is not good
This may be the case if you go to an inexperienced surgeon. You should ask your surgeon how many cases they undertake a year. If this number is low (<50) you may wish to consider an alternate surgeon.
www.bucksendocrine.com
www.thyroidsurgeon.org.uk
Follow us on Twitter
There seems to be a common theme from these patients usually resulting in delays in diagnosis and generally getting sorted out. I thought it might be helpful to list some of the issues:
1. Calcium only slightly elevated
As a result of only tiny elevations in calcium it is often said that there is not a problem. This is incorrect. Calcium levels should be in the normal range - if not you need to work out why not and only then can a decision be made as to what to do.
2. PTH level normal
PTH levels should be almost zero if the calcium is high as the glands are supposed to switch off and stop making PTH. If PTH levels are normal we term this 'inappropriately elevated' and it suggests primary parathyroid disease.
3. Mildly elevated calcium and parathyroid disease is OK
No it is not. Calcium levels and indeed parathyroid hormone levels are completely unrelated to symptoms so some patients have terrible symptoms even with mildly elevated calcium.
Calcium levels do not make a difference to osteoporosis. So if you have the disease you can develop osteoporosis and it makes no difference how high the calcium level is
4. Surgery is not good
This may be the case if you go to an inexperienced surgeon. You should ask your surgeon how many cases they undertake a year. If this number is low (<50) you may wish to consider an alternate surgeon.
www.bucksendocrine.com
www.thyroidsurgeon.org.uk
Follow us on Twitter
Thursday, 23 June 2011
Graves Disease and Thyroid Surgery
Graves disease is caused by an antibody made by the body's own immune system which attacks the eyes and thyroid gland.
In the thyroid gland the result is overproduction of thyroid hormone.
The treatment is to bring the thyroid under control with anti-thyroid medication. These drugs have significant side effects and there is a risk of agranulocytosis (loss of all white blood cells) which means patients cant fight infection and can become very ill.
Drugs usually work well and after a year if all is controlled they can be stopped and many patients will be cured. For those where the disease relapses it is essential to restart the drugs and seek a definitive treatment.
There are two definitive treatments:
1. Radioactive iodine
2. Total thyroidectomy
I wont discuss radio-iodine here but it is good for small thyroids and patients without eye problems.
Surgery should always be a total thyroidectomy. Some surgeons still offer a sub-total thyroidectomy which is a poor operation.
Sub-total surgery leaves bits of the thyroid behind and this means the tissue can regrow and the disease come back - a crazy situation when it could all be taken away at the first operation.
Surgery is a good option for many people and is offered along the lines of minimal access thyroid surgery.
www.bucksendocrine.com
www.thyroidsurgeon.org.uk
In the thyroid gland the result is overproduction of thyroid hormone.
The treatment is to bring the thyroid under control with anti-thyroid medication. These drugs have significant side effects and there is a risk of agranulocytosis (loss of all white blood cells) which means patients cant fight infection and can become very ill.
Drugs usually work well and after a year if all is controlled they can be stopped and many patients will be cured. For those where the disease relapses it is essential to restart the drugs and seek a definitive treatment.
There are two definitive treatments:
1. Radioactive iodine
2. Total thyroidectomy
I wont discuss radio-iodine here but it is good for small thyroids and patients without eye problems.
Surgery should always be a total thyroidectomy. Some surgeons still offer a sub-total thyroidectomy which is a poor operation.
Sub-total surgery leaves bits of the thyroid behind and this means the tissue can regrow and the disease come back - a crazy situation when it could all be taken away at the first operation.
Surgery is a good option for many people and is offered along the lines of minimal access thyroid surgery.
www.bucksendocrine.com
www.thyroidsurgeon.org.uk
Wednesday, 8 June 2011
Vitamin D and Parathyroid Disease
This topic discusses the importance of vitamin D and its link with primary parathyroid disease.
Vitamin D is required by the body to allow us to absorb calcium from the foods we eat. It is for this reason that many calcium supplements are made with vitamin D added to them as without it the intestines cannot absorb the calcium in the pill.
Vitamin D is made in the skin when the skin is exposed to sunlight.
There is some evidence that when someone starts developing parathyroid disease and the calcium levels rise the body uses vitamin D as a protective mechanism. The basic concept is that as the calcium starts to go up the body limits the amount of vitamin D made which reduces the amount of calcium the body can absorb from the diet.
The end result is that vitamin D levels go lower than normal.
A large study looking at this in nearly 1600 patients with parathyroid disease found that 67% of all patients with parathyroid disease have low levels of vitamin D. There also appeared to be a trend to vitamin D being lower the higher the level of calcium went.
This is an observational study and we do not know the mechanism for this however it does illustrate that vitamin D levels are likely to be low with parathyroid disease.
Occasionally endocrinologists recommend taking extra vitamin D in this situation. Generally this does nothing but it can have the paradoxical effect of increasing blood calcium levels - presumably as the absorption of calcium from the intestine improves.
So correcting the vitamin D level is not the answer for the calcium levels. Calcium levels are only very rarely high due to low vitamin D. What is usually needed is consideration of parathyroid surgery to cure the problem. Vitamin D levels can be corrected easily after surgery.
www.bucksendocrine.com
www.thyroidsurgeon.org.uk
Vitamin D is required by the body to allow us to absorb calcium from the foods we eat. It is for this reason that many calcium supplements are made with vitamin D added to them as without it the intestines cannot absorb the calcium in the pill.
Vitamin D is made in the skin when the skin is exposed to sunlight.
There is some evidence that when someone starts developing parathyroid disease and the calcium levels rise the body uses vitamin D as a protective mechanism. The basic concept is that as the calcium starts to go up the body limits the amount of vitamin D made which reduces the amount of calcium the body can absorb from the diet.
The end result is that vitamin D levels go lower than normal.
A large study looking at this in nearly 1600 patients with parathyroid disease found that 67% of all patients with parathyroid disease have low levels of vitamin D. There also appeared to be a trend to vitamin D being lower the higher the level of calcium went.
This is an observational study and we do not know the mechanism for this however it does illustrate that vitamin D levels are likely to be low with parathyroid disease.
Occasionally endocrinologists recommend taking extra vitamin D in this situation. Generally this does nothing but it can have the paradoxical effect of increasing blood calcium levels - presumably as the absorption of calcium from the intestine improves.
So correcting the vitamin D level is not the answer for the calcium levels. Calcium levels are only very rarely high due to low vitamin D. What is usually needed is consideration of parathyroid surgery to cure the problem. Vitamin D levels can be corrected easily after surgery.
www.bucksendocrine.com
www.thyroidsurgeon.org.uk
Subscribe to:
Posts (Atom)