I get a lot of enquiries from patients who are wishing to transfer care from their local area.
The previous government set up a system called Patient Choice and as part of this set out a series of rights for patients within the NHS in England - Scotland and Wales are separate from this.
As part of Patient Choice (more details on the NHS website) every NHS patient is entitled to be referred by their GP to a consultant of their choice. This can be anywhere in England and your GP should not restrict you to just your local area.
In practice most GPs are entirely aware of the entitlements so as long as you are clear in what you would like to do this is not really a problem.
I encourage patients to be referred by their GP as this will allow for safe and efficient transfer of information - in particular past medical history, blood tests and other investigation results.
For patients from out of area we operate a very efficient service where I will endeavour to see you, undertake all tests the same day and then you simply come back for surgery - a 2 stop service!
Bucksendocrine - Thyroid and Minimal Access Parathyroid Surgery
Thyroid Surgery by a UK specialist surgeon
Monday, 23 April 2012
Sunday, 18 March 2012
Calcium Levels and Diagnosing Parathyroid Disease
Calcium levels in the blood are controlled in a very tight range - in the UK levels are given on blood tests such that the normal range is between 2.2 and 2.55 mmol/l. This varies between laboratories and hospitals but not by much.
Key Point 1 - A high calcium is never normal
Calcium levels are controlled by the parathyroid glands which make parathyroid hormone (PTH). The 4 parathyroid glands have a really big blood supply and can monitor calcium levels really effectively. Contol of calicum is in a very narrow range.
Key Point 2 - Calcium levels will fluctuate on a day to day basis
So calcium levels if checked and are just outside normal can be rechecked and may a few days later be in the normal range. Some patients with parathyroid disease who have calcium levels that are marginally elevated will therefore dip into normal from time to time - this can make the diagnosis difficult.
Key Point 3 - What to do if calcium is high
Calcium levels should be rechecked along with a PTH level. If the calcium is high PTH levels should be almost zero because like your boiler their internal thermostat (measuring calcium not temperature) should have switched them off.
If PTH levels are in the 'normal' range and calcium is high you almost certainly have parathyroid disease as the calcium levels are inappropriately elevated as they should be near zero.
Key Point 4 - Symptoms are not linked to calcium level
Many patients will have marginally elevated calcium levels and yet have terrible symptoms. Some will have very high calcium and no symptoms. The absolute numbers are of no great relevance. All patients with parathyroid disease should have a discussion about treatment with someone who understands the disease.
More information on:
Parathyroid Surgery
Parathyroid and Minimal Access Thyroid Surgery
Key Point 1 - A high calcium is never normal
Calcium levels are controlled by the parathyroid glands which make parathyroid hormone (PTH). The 4 parathyroid glands have a really big blood supply and can monitor calcium levels really effectively. Contol of calicum is in a very narrow range.
Key Point 2 - Calcium levels will fluctuate on a day to day basis
So calcium levels if checked and are just outside normal can be rechecked and may a few days later be in the normal range. Some patients with parathyroid disease who have calcium levels that are marginally elevated will therefore dip into normal from time to time - this can make the diagnosis difficult.
Key Point 3 - What to do if calcium is high
Calcium levels should be rechecked along with a PTH level. If the calcium is high PTH levels should be almost zero because like your boiler their internal thermostat (measuring calcium not temperature) should have switched them off.
If PTH levels are in the 'normal' range and calcium is high you almost certainly have parathyroid disease as the calcium levels are inappropriately elevated as they should be near zero.
Key Point 4 - Symptoms are not linked to calcium level
Many patients will have marginally elevated calcium levels and yet have terrible symptoms. Some will have very high calcium and no symptoms. The absolute numbers are of no great relevance. All patients with parathyroid disease should have a discussion about treatment with someone who understands the disease.
More information on:
Parathyroid Surgery
Parathyroid and Minimal Access Thyroid Surgery
Thursday, 12 January 2012
Minimal Access Parathyroid Surgery Video
Mr McLaren performing minimal access parathyroid surgery. Note the small incision size and 2.5cm adenoma being removed.
This operation is available as a daycase procedure to NHS and private patients and most do not require any painkillers after the surgery.
Video of Minimal Access Parathyroid Surgery
More information on the service provided is available on:
http://www.bucksendocrine.com/
http://www.thyroidsurgeon.org.uk/
This operation is available as a daycase procedure to NHS and private patients and most do not require any painkillers after the surgery.
Video of Minimal Access Parathyroid Surgery
More information on the service provided is available on:
http://www.bucksendocrine.com/
http://www.thyroidsurgeon.org.uk/
Saturday, 3 December 2011
Thyroid Cysts
Thyroid cysts are a common cause of a lump in the thyroid gland
They usually arise quite quickly and are a cause of a suddenly noticed and often slightly painful lump in the neck
Thyroid cysts are diagnosed by being referred to a specialist thyroid clinic where a needle biopsy will be done there and then - removing the fluid means the cysts is gone!
Once the fluid is removed your consultant will re-examine the neck and confirm that all the lump has gone as well - this confirms the diagnosis of a cyst. An ultrasound scan is NOT required and usually just acts as a delaying scan adding absolutely nothing to the diagnosis.
As a matter of routine the fluid should be sent off for cytological assessment to check there are no cancerous cells.
Management of the cyst depends on how it behaves:
1. The cyst goes away and stays away - a check exam in 1 month to confirm this and then you should be discharged from further review.
2. If it recurs a further needle aspiration of the fluid may well cure it.
3. If it recurs again I now generally get an ultrasound drainage done to make 100% certain all the fluid is removed
4. If the cyst keeps on recurring this is an indication for surgery - usually a thyroid lobectomy (removing half the thyroid containing the cyst)
The reason for operating on recurrent cysts is that many of these have a growth in the wall producing fluid hence why it keeps coming back. Some of these growths are thyroid cancers - hence the concern about managing them correctly.
Mr McLaren offers this service in both the NHS and private sectors and more details are available on the websites below
Bucksendocrine - thyroid surgery by a UK specialist surgeon
Thyroid and Parathyroid Surgery Website
Video of Mr McLaren undertaking a thyroid operation
They usually arise quite quickly and are a cause of a suddenly noticed and often slightly painful lump in the neck
Thyroid cysts are diagnosed by being referred to a specialist thyroid clinic where a needle biopsy will be done there and then - removing the fluid means the cysts is gone!
Once the fluid is removed your consultant will re-examine the neck and confirm that all the lump has gone as well - this confirms the diagnosis of a cyst. An ultrasound scan is NOT required and usually just acts as a delaying scan adding absolutely nothing to the diagnosis.
As a matter of routine the fluid should be sent off for cytological assessment to check there are no cancerous cells.
Management of the cyst depends on how it behaves:
1. The cyst goes away and stays away - a check exam in 1 month to confirm this and then you should be discharged from further review.
2. If it recurs a further needle aspiration of the fluid may well cure it.
3. If it recurs again I now generally get an ultrasound drainage done to make 100% certain all the fluid is removed
4. If the cyst keeps on recurring this is an indication for surgery - usually a thyroid lobectomy (removing half the thyroid containing the cyst)
The reason for operating on recurrent cysts is that many of these have a growth in the wall producing fluid hence why it keeps coming back. Some of these growths are thyroid cancers - hence the concern about managing them correctly.
Mr McLaren offers this service in both the NHS and private sectors and more details are available on the websites below
Bucksendocrine - thyroid surgery by a UK specialist surgeon
Thyroid and Parathyroid Surgery Website
Video of Mr McLaren undertaking a thyroid operation
Thursday, 6 October 2011
Modern Thyroid Surgery - The Harmonic Scalpel
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
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
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
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