GUIDELINES FOR THE SURGICAL MANAGEMENT … · Cushings Syndrome 12 Primary Hyperaldosteronism -...

GUIDELINES FOR THE SURGICAL

MANAGEMENT OF ENDOCRINE DISEASE

AND

TRAINING REQUIREMENTS FOR

ENDOCRINE SURGERY

THE BRITISH ASSOCIATION OF

ENDOCRINE SURGEONS

2 Guidelines for the Surgical Management of Endocrine Disease

CONTENTS

1 GUIDELINES 3

2 SURGICAL TREATMENT OF DISEASES OF THE THYROID GLAND

2.1 MANAGEMENT OF PATIENTS WITH NODULAR GOITRE 42.2 THYROID MALIGNANCY 5

Follicular Cancer 6Medullary Thyroid Cancer (MTC) 7Thyroid Lymphoma 8

2.3 ANAPLASTIC THYROID CANCER 82.4 THYROTOXICOSIS 9

3 SURGICAL TREATMENT OF THE PARATHYROID GLANDS

3.1 PRIMARY HYPERPARATHYROIDISM 103.2 RENAL HYPERPARATHYROIDISIM

(Secondary or Tertiary Hyperparathyroidism) 11

4 SURGICAL TREATMENT OF DISEASES OF THE ADRENAL GLAND

Investigations 12Cushings Syndrome 12Primary Hyperaldosteronism - Adrenocortical Adenoma-Conn’s Syndrome 12Phaeochromocytoma 12Incidentaloma 12Adrenocortical Carcinoma 13

5 SURGICAL TREATMENT OF THE ENDOCRINE PANCREAS

5.1 INSULINOMA 145.2 GASTRINOMA (Zollinger-Ellison Syndrome) 14

6 PATIENT INFORMATION SHEETS

6.1 THYROIDECTOMY FOR BENIGN NODULAR DISEASE OF THE THYROID 17

6.2 THYROTOXICOSIS (Overactive Thyroid) 196.3 ADVICE TO PATIENTS LEAVING HOSPITAL AFTER

ADMINISTRATION OF 131-IODINE 216.4 RENAL HYPARATHYROIDISM (RHPT) 226.5 PRIMARY HYPERPARATHYROIDISM (HPT) 24

APPENDIX 1 - TRAINING REQUIREMENTS AND CURRICULUM FOR ENDOCRINE SURGERY

Requirements for Training in Endocrine Surgery 26Basic Science Curriculum 26Clinical Curriculum 27Index Cases 28To be a General Surgeon with an interest in Endocrine Surgery 28To be a Sub-Specialist in Endocrine Surgery 28

Guidelines for the Surgical Management of Endocrine Disease 3

GUIDELINES

The British Association of Endocrine Surgeons (BAES) is the representative body of British surgeons who have a specialinterest in the surgery of the endocrine glands other than the pituitary. The Association is recognised by the Department ofHealth, The Association of Surgeons of Great Britain and Ireland and the British Association of Surgical Oncology. TheBAES advises the SAC and the Intercollegiate Board on the Curriculum for Training in Endocrine Surgery.

In 1998, Members of the Association at the Annual Meeting mandated the Executive to form a working party for thepurpose of drafting Guidelines for recommended practice in endocrine surgery. The general membership of the BAES hadthe opportunity to review and comment on the Guidelines which were first published in 1999.

The Guidelines represent core standards for clinical practice and it is expected that they will evolve and be subjected toregular revision. The BAES has contributed to the National Thyroid Cancer Guidelines Group which has produced anevidence based document on the surgical and non surgical management of thyroid cancer. In recognising that much ofsurgery is not based on randomised controlled trials, especially for rarer conditions such as endocrine disease, the guidelinesare a consensus on what might be considered “best practice”.

The Guidelines do not define an endocrine surgeon or specify who should practice endocrine surgery. There will besurgeons who, with the help of Guidelines and their existing clinical experience will be able to manage some thyroid andparathyroid diseases to the highest standard. Elective endocrine surgery may not be in the portfolio of every DistrictHospital but, where it is, based on experience and caseload, it should be in the hands of a nominated surgeon with anendocrine interest. Those patients requiring more complex investigation and care as detailed in these guidelines should bereferred to an appropriate centre. These rare and complex diseases will only be managed effectively by multidisciplinaryteams in Units familiar with these disorders. We consider that this category includes patients with endocrine pancreatictumours, adrenal tumours, thyroid malignancy, familial syndromes and those requiring reoperative thyroid and parathyroidsurgery.

Audit with outcome analysis is critical to the credibility of any surgical team. Such audit should produce data to allowmeaningful comparison between units. Participation in the BAES Audit is a requirement for recognition as an EndocrineUnit and for endocrine training and is also a condition of membership of the BAES. It is intended that analysis of audit datawill inform future modifications of these guidelines.

The BAES supports the principles of structured information for patients and documented informed consent and thereforeexamples of suitable forms are enclosed.

In future, all surgeons undertaking endocrine surgery should be able to demonstrate that they have been specifically trainedin the subject. The current SAC requirements for endocrine surgical training are therefore appended to this documenttogether with a curriculum for endocrine surgery previously developed and approved by the BAES.

These revised Guidelines for the Surgical Management of Endocrine Disease and the Training Requirements for EndocrineSurgery were produced by the BAES Guidelines and Training Sub-group; and revised in 2003, they will be further revisedin 2006.

The address of the BAES Office is:

BAES OfficeC/o Association of Surgeons of Great Britain and IrelandAt the Royal College of SurgeonsLincolns Inn FieldsLONDON WC2A 3PE

Tel: 0207 430 9235Fax: 0207 430 9235

e-mail: [email protected]


SURGICAL TREATMENT OF DISEASES OF THETHYROID GLAND

2.1 MANAGEMENT OF PATIENTS WITHNODULAR GOITRE

INTRODUCTION

Nodular goitre is the commonest surgical endocrinedisease and may be managed by the general as well as thespecialist surgeon.

CLINICAL ASSESSMENT

Clinically identified thyroid nodular disease should becategorised as:* Solitary nodule* Dominant nodule within a multinodular goitre* Multinodular goitre

The clinical assessment of all patients should assess theexistence of obstructive problems or tracheal deviation,should elicit any features of malignant disease, shouldidentify if there is a family history of thyroid disease andshould determine whether there is a history of externalbeam radiotherapy to the thyroid, mantle or head and neck.

INVESTIGATIONS

These should include:* Blood tests - thyroid function tests - TSH (Free T4/T3,

if the TSH is abnormal) and Calcium/Albumin prior toany neck exploration.

* Thyroid Auto-antibody estimation may predict postlobectomy hypothryroidism and assist in theinterpretation of thyroid function tests.

* Fine Needle Aspiration biopsy is indicated for all solitarynodules and for all dominant nodules in multi-nodulargoitres. Cytology is unable to differentiate follicular adenomas from carcinomas and has difficulty in

differentiating lymphoma from thyroiditis and anaplasticcarcinoma. Ultrasound guided core biopsy may be ofvalue when freehand biopsy is difficult.

* Ultrasound may differentiate solid from cystic nodulesshow solid components in a cystic nodule, identifymultinodularity, identify associated lymphadenopathy

BUT cannot reliably distinguish between benign andmalignant lesions.

* Istotope Scan. This is only indicated in a patient with anodule who is thyrotoxic and considered for surgery.

* CT/MRI/CXR These are indicated in patients withretrosternal goitre, for assessment of tracheal narrowingor deviation or, as part of preoperative assessmentaccording to local protocols.

OTHER TESTS

* Pulmonary Function tests may assist the assessment of a patient with clinical evidence of airway embarrassment.

* Laryngoscopy. This is indicated where the patient has ahistory of voice change, previous thyroid surgery or is tobe operated on for thyroid malignancy.

INDICATIONS FOR SURGERY IN NODULAR DISEASE

* Cytological features of papillary or medullary cancer or afollicular lesion (adenoma or carcinoma)

* Clinical suspicion of malignancy

* Pressure signs or symptoms

* Patient preference – cosmesis/anxiety

* Toxicity (toxic adenoma or toxic multinodular goitremay be appropriate for radioactive iodine treatment)

* Progressive enlargement in a retrosternal goitre

* Discomfort in a goitre or associated with its presence

PREPARATION FOR SURGERY

Patients undergoing surgery for thyroid nodular disease mustbe informed of the risks of thyroid surgery – see Section 6.1

SURGERY FOR BENIGN NODULAR DISEASE

Subtotal lobectomy for nodular goitre results in a 15%recurrence rate ultimately requiring re-operation.Recurrent nerve palsy rates are higher at re-operation.

SOLITARY NODULE

* Total lobectomy or isthmusectomy is recommended.

* No firm recommendation can be made on the value offrozen section for routine use in patients with benigncytology. Its use and value will be determined by localskills and protocols.

* The recurrent laryngeal nerve must be clearly identifiedand safeguarded in all patients. The superior laryngealnerve should be safeguarded by careful ligation of thesuperior thyroid vessels at the margin of the capsule.

* Parathyroid glands should be identified and safeguarded.We recommend visualisation and preservation of allnormal parathyroid glands.

* It is recommended that the branches of the inferiorthyroid artery are ligated adjacent to the thyroid capsuleto preserve the blood supply to the parathyroid glands inpreference to continuity ligation of the trunk of the vessellaterally.

* There is no evidence that routine drainage is essential.

* Routine thromboembolic chemoprophylaxis is notrecommended because of the risk of haematomaformation in the neck, but other DVT precautions areadvised.


MULTINODULAR GOITRE

* Biochemical toxicity must be controlled prior to surgery.

* Unilateral surgery may be indicated when only one lobeis severely affected but, when there is significantinvolvement of both lobes, then total/near totalthyroidectomy is recommended.

* Recurrent laryngeal nerves must be clearly identified andsafeguarded. The superior laryngeal nerve on each sideshould be safeguarded by careful ligation of the superiorthyroid vessels.

* Every effort must be made to preserve parathyroidglands.

*All parathyroid glands excised with the thyroid should bere-implanted, after dicing, into adjacent muscle. Detailsshould be recorded in the operation notes.

* Retrosternal extension of a multinodular goitre should besought. Most retrosternal goitres can be removed via a cervical incision.

* Risk factors that may identify patients who requiresternotomy include – previous thyroid surgery, extensionto a level below the aortic arch, significant posterior mediastinal extension.

POSTOPERATIVE MANAGEMENT

* We recommend that serum calcium should be checkedwithin the first 24 hours of surgery and subsequently if abnormal. Calcium replacement may be indicatedwhen the corrected calcium falls below 2mM/1.Intravenous calcium gluconate is normally indicated fora corrected calcium below 1.8mM/1 or if the patient issymptomatic. Patients must not be discharged until thecalcium level is stable without intravenous calciumadministration in the preceding 24 hours.

* Facilities and a written protocol must be available for themanagement of airway obstruction or woundhaemorrhage.

* Accurate assessment of vocal cord function can only be obtained by formal laryngoscopy in the consciouspatient. It is best performed by a practitioner withexpertise such as an ENT surgeon. It is not essentialpostoperatively in every case but is recommended inpatients with persisting postoperative voice change.

* All patients undergoing thyroidectomy should have TSHlevels checked at follow-up. Patients undergoing total thyroidectomy should commence Thyroxine prior todischarge from hospital.

2.2 THYROID MALIGNANCYThe evidence base relating to the management of thyroidcarcinoma is predominantly in the form of retrospectivereviews of single centres’ management of the condition.There are no prospective randomised studies. However thefollowing guidelines are consistently supported by theavailable evidence.Surgery for thyroid cancer should be performed by

endocrine surgeons or surgeons with an interest inendocrine surgery with appropriate training. This surgeryshould be carried out in a unit with access to appropriatecytology, pathology, endocrinology and oncology support.

PAPILLARY THYROID CANCER

DIAGNOSIS

The diagnosis may be made or suspected on clinicalgrounds (usually presenting with a dominant nodule) onpreoperative aspiration cytology or a previous operation(e.g. lymph node biopsy, thyroid operation or lungresection). It may be made on intraoperative frozen sectionor postoperative definitive histology.

INVESTIGATION

* Clinical examination of the neck is required to identifypalpable abnormalities in the thyroid, adjacent structuresand related lymph nodes.

* Fine needle aspiration biopsy is mandatory for dominantor isolated thyroid swellings. It should be performed atthe first clinic visit.

* A chest radiograph is required.

* Routine preoperative imaging with scintigraphy or ultra-sonography is not recommended, but imaging with CT orMRI may be indicated in patients with extensive or recurrent disease.

* Patients undergoing thyroid surgery should have thyroidfunction and serum calcium recorded prior to operation.

* Preoperative laryngoscopy is indicated in the presenceof voice change, clinically suspected or proven malignant disease.


Patients undergoing surgery for papillary thyroid cancermust be informed of the risks of thyroid surgery and theincreased risks associated with more radical surgery formalignant disease (viz hypoparathyroidism and recurrentlaryngeal nerve injury). See Section 6.1.

SURGICAL TREATMENT

* The objective of surgery is to remove all macroscopicmalignant disease in the thyroid, draining lymph nodesand involved adjacent structures.


*A tumour of 1 cm diameter or less with no palpablelymphadenopathy or clinically overt disease in thecontralateral lobe or evidence of distant metastases cansafely be managed by total lobectomy alone.

* Patients with macroscopic nodal disease and/or distantmetastases, patients with clinical evidence of bilateral ormultifocal unilateral disease should undergo totalthyroidectomy.

* Patients treated by unilateral lobectomy who are shownon histology to have multifocal disease should beconsidered for complete thyroidectomy.

* Patients with macroscopic lymphadenopathy should bemanaged by lymph node excision which conserves nonlymphatic structures. Radical forms of block dissectionof the neck which sacrifice non lymphatic structures arenot indicated unless those structures are infiltrated bytumour.

* There is controversy concerning the extent of thyroidsurgery with solitary tumours greater than l cm in diameter without evidence of lymph node or distantmetastases. The published evidence does not clarifywhether lobectomy near total or total thyroidectomy ismost likely to improve outcome.

* Extensive extra thyroidal disease in the neck is usuallyassociated with a poor prognosis and surgery which ismore radical than total thyroidectomy and lymph nodedissection is not routinely recommended.

* Surgery should minimise the risk of avoidable injury tothe recurrent and superior laryngeal nerves and attempt toconserve functioning parathyroid tissue.

TUMOUR STAGING

We advise that pathological TNM staging is recorded forall patients with papillary thyroid cancer to facilitatecomparative studies of treatment and outcome(local/regional/systemic relapse and death). Description ofthe resected tumour should be according to Royal Collegeof Pathologists minimum data set.Post operative management is as for benign disease, with

the exception of thyroid replacement therapy.

* If the patient has undergone total thyroidectomy they areplaced initially onto Tri-iodothyronine 20 µg tds andconsidered for radioactive iodine scanning and therapy.TSH suppression with T4 is recommended in the longterm following surgery for papillary thyroid cancer. Patients who have undergone thyroidectomy for franklyinvasive lesions will require surveillance in a specialistclinic with monitoring of TSH and thyroglobulin. Risingserum thyroglobulin levels are a marker of recurrent disease; levels should always be interpreted with care due to variation between laboratories and the confounding effects of anti-thyroglobulin antibodies.

* All patients diagnosed with papillary thyroid cancershould be reviewed by the Cancer Centre designatedspecialist multidisciplinary team.

RECURRENT DISEASE

Recurrence may be detected clinically by detection ofrising thyroglobulin levels or, on follow-up radioiodinescanning. Palpable disease should be assessed by FineNeedle Biopsy and CT/MRI/USS.Options for the treatment of recurrent disease include

further surgery, radioiodine or external radiotherapy.Management decisions in these circumstances should bemade by a multidisciplinary team.(See also the British Thyroid Association Guidelines on

the treatment of Thyroid Cancer:http://www.british-thyroid-association.org/)

FOLLICULAR THYROID CANCER

DIAGNOSIS

Most patients will be referred with a solitary thyroidnodule perhaps recently increasing in size. Pressuresymptoms, hoarseness of voice and pain often radiatinginto the jaw and face are particularly relevant.

INVESTIGATION

* Fine needle aspiration biopsy is mandatory for dominantor isolated thyroid swellings. It should be performed atthe first clinic visit, or by ultrasound guided technique.

* A chest radiograph is required.

* Routine preoperative imaging with scintigraphy orultrasound is not recommended prior to a first operation,but imaging with CT or MRI may be indicated in patientswith extensive or recurrent disease.

* Patients undergoing thyroid surgery should have thyroidfunction and serum calcium recorded prior to operation.

* Preoperative laryngoscopy is indicated in the presence of voicechange, clinically suspected or proven malignant disease.


Patients undergoing surgery for follicular cancer must beinformed of the risks of thyroid surgery and the increasedrisks associated with more radical surgery for malignantdisease (viz hypoparathyroidism and recurrent laryngealnerve injury). See Section 6.1.

SURGICAL TREATMENT

* All follicular neoplasms should be treated by surgicalexcision. i.e. thyroid lobectomy and isthmectomy.

* Definitive histology may indicate the need forcompletion thyroidectomy.

* Lesions which after adequate pathological evaluation arefound to have no capsular or vascular invasion are not consideredmalignant and lobectomy is sufficient treatment.


* Total thyroidectomy is recommended where there isclear evidence of vascular or full thickness capsularinvasion.

* Patients with lesions showing minimal capsular invasionalone may be treated by unilateral lobectomy.

* From the evidence available it is difficult to make firmrecommendations for the treatment of follicular thyroidcancer with full thickness capsular invasion and noevidence of vascular invasion. Total thyroidectomy andradioiodine ablation allows post treatment surveillancewith serial thyroglobulin measurements andidentification/treatment of metastases with radioiodine.

* Hurthle cell tumours (Oxyphil) may behave moreaggressively. Malignant Hurthle cell tumours are lesslikely to concentrate radioiodine and there is a case fortreating them by total thyroidectomy.

TUMOUR STAGING

We advise that pathological TNM staging is recorded forall patients with follicular thyroid cancer to facilitatecomparative studies of treatment and outcome(local/regional/systemic relapse and death) – see page 6

POST-OPERATIVE MANAGEMENT

As for papillary thyroid cancer, all patients diagnosed withfollicular thyroid cancer should be reviewed by the CancerCentre designated specialist multidisciplinary team.

MEDULLARY THYROID CANCER (MTC)

This is a rare tumour which can occur in four clinical settings:* Sporadic* Familial

(a) as part of multiple endocrine neoplasia type IIa (b) aspart of multiple endocrine neoplasia type IIb (c) asfamilial medullary thyroid cancer without otherendocrine disease (FMTC)

Although appearing microscopically identical, thebehaviour of the MTC varies according to the setting. Thetumour is most indolent in FMTC and most aggressive inMEN IIb. The spectrum from indolent to aggressive is:FMTC * MEN IIa * Sporadic * MEN IIb. The familialforms are inherited autosomal dominant conditions – thereis a 50/50 chance of any child of an affected parentinheriting the condition.Surgery for medullar thyroid cancer should be performed

by an endocrine surgeon in a unit with access toappropriate support in cytology, biochemistry, clinical andmolecular genetics, endocrinology and oncology.

DIAGNOSIS

The disease may present as a solitary thyroid nodule or aslymph node enlargement. Cytology is characteristic inMTC and should prompt a specific diagnosis. A positivefamily history of thyroid tumours will suggest a diagnosisof familial MTC.

PRE-OPERATIVE INVESTIGATIONS IN ALL CASES

* The surgeon has the responsibility to distinguish betweenfamilial and sporadic disease and to excludephaeochromocytoma in all cases.

* Whether the disease appears to be sporadic or familial,pre-operative or intra-operative staging should include:

* Basal calcitonin levels.

* Ultra-sonography of the neck to determine if there aremultiple thyroid nodules or lymphadenopathy, orMRI/CT scans to assess the potential burden of cervicaland/or mediastinal disease.

INVESTIGATIONS IN FAMILIAL CASES

In the presence of a family history suggestive of MEN 2 orFMTC family genetic screening is required. It must beremembered that absence of family history does notpreclude this patient being the index case for a newkindred.Absence of biochemical expression (elevated calcitonin)

in a relative of an index case after the age of 40 coupledwith absence of a germ line mutation and the presence of asomatic mutation in the tumour suggests sporadic disease.

MOLECULAR GENETICS

Ninety-seven percent of individuals with MEN IIa havegerm line mutations in the RET gene and 99% of thosewith MEN IIb have a RET germ line mutation in codon918. Up to 80% of those with FMTC have these mutations.Within proven kindreds these molecular tests should,wherever and whenever possible, be used to diagnosedisease in family members at risk (ante- and post-cedent).Children with these mutations should be offeredprophylactic surgery. Provocative biochemical testing isnot required in RET positive individuals but baselinecalcitonin concentrations should be taken, though they maybe normal in the presence of MTC.The unit must be able to manage the logistics, ethics,

clinical genetics and treatment of patients, includingchildren, with inherited disease.


Preoperative laryngoscopy is indicated in the presence of voicechange, clinically suspected or proven malignant disease.Patients must be informed of the risks of thyroid surgery

and the increased risk of more radical surgery –hypoparathyroidism and recurrent laryngeal nerve injury –see Section 6.1.

SURGICAL TREATMENT

The prime objective in surgery is to remove all malignancyin the thyroid, draining lymph nodes and adjacentstructures. This usually requires total thyroidectomy andcentral compartment lymph-adenectomy. Patients withsporadic tumours may have a single focus of disease in onelobe but, because of its aggressive nature and multifocality,total thyroidectomy is still recommended.


Total thyroidectomy should include clearance of thecentral and paratracheal nodes from the level of the thyroidcartilage to the upper mediastinum and include a cervicalthymectomy. The lateral nodes, if enlarged or suspiciousaround the jugular veins on each side, can be sampled andsubjected to frozen section histology. If involvement ispresent, a modified neck dissection of the affected nodegroups should be performed at the time of the firstoperation sparing the jugular vein, the sternomastoidmuscle and the accessory nerve.Thyroidectomy should minimise the risk of avoidable

injury to the recurrent laryngeal nerves and attempt toconserve functioning parathyroid tissue. If preoperativeinvestigations have demonstrated associated hyper-parathyroidism, enlarged glands should be removed at thetime of thyroid exploration.Prophylactic thyroidectomy is indicated in kindred

members without clinically apparent disease but who arecarriers of the germ line RET mutation. There is no currentevidence on which to base a firm recommendation for theage at which prophylactic surgery should be performedbut, on current knowledge, it should be between four andseven years of age. Emerging evidence suggests thatcertain RET mutations are associated with early andaggressive phenotypes of the disease requiring earlyoperation (e.g. Men IIb) but others may have a lessaggressive form and surgery can be postponed.


Adequate replacement with thyroxine is required.Suppressive doses of thyroxine are not necessary andThyroglobulin is not used as a marker in patients with thistype of thyroid cancer. There is no role for postoperativeiodine scanning in MTC. Calcitonin is used as a marker ofrecurrent or persistent disease. All patients diagnosed withmedullary thyroid cancer should be reviewed by theCancer Centre designated specialist multidisciplinary team.Life long surveillance is required in a specialist endocrine

clinic where biochemical and radiological expertise isavailable to detect and localise clinically apparent/occultdisease. In patients with MEN II an annual test to excludehyperparathyroidism and phaeochromocytoma should beperformed.

TUMOUR STAGING

We advise that pathological TNM staging is recorded forall patients with medullary thyroid cancer to facilitatecomparative studies of treatment and outcome(local/regional/systemic relapse and death) – see page 6.

PATHOLOGY

If MTC is diagnosed only after a hemithyroidectomy thencompletion thyroidectomy and central node clearance asdescribed above should be undertaken.Surgeons should seek advice from colleagues in clinical

genetics about every case of diagnosed MTC [vide supra].Familial disease is implied when there is multifocal,

bilateral malignancy with or without a background of C-cell hyperplasia and in these cases germ line RET mutationanalysis is mandatory.

RECURRENT OR PERSISTENT DISEASE

When persisting or recurrent disease is suggested by risinglevels of tumour markers, an attempt should be made tolocate the disease by appropriate imaging which mayinvolve Ultrasound, CT/MRI and scanning with octreotide,pentavalent DMSA or MIBG. The nature of palpablerecurrences should be confirmed with FNAB. Accessiblefocal recurrences in the neck may be treated by excisionbut there is little evidence that radical re-operative surgeryis beneficial. Patients with confirmed recurrent diseaseshould be managed by a specialist multidisciplinary teamso that all forms of palliative treatment can be considered.There may be a limited role for external beam radiotherapyor chemotherapy. There is no role for radioiodine therapyfor patients with these tumours.

THYROID LYMPHOMA

Thyroid Lymphoma may present as a dominant nodule, anodular goitre, or an ‘inflammatory mass’. Surgery haslittle value in treatment.

DIAGNOSIS

Thyroid function is usually normal but abnormal titres ofthyroid auto-antibodies may be detected.Fine Needle Aspiration cytology may be used to

distinguish lymphoma from lymphocytic thyroiditis butusually the diagnosis is difficult, especially indistinguishing lymphoma from anaplastic carcinoma.Core biopsy is necessary to allow immunohistochemical

sub-typing of the lymphoma which will have implicationsfor further treatment. It is recommended that this isundertaken in theatre or with image-guidance (USI-core).Open biopsy is rarely needed.

TREATMENT

All patients diagnosed with thyroid lymphoma should bereviewed by the Cancer Centre designated specialistmultidisciplinary team.When a diagnosis of lymphoma has been established by

FNA or core biopsy, oral/parenteral steroids are of value totreat acute symptoms of airway compromise rapidly.When the diagnosis has been made the patient must be

referred promptly to an oncologist or haematologist forstaging and definitive treatment with radiotherapy and/orchemotherapy.

2.3 ANAPLASTIC THYROID CANCER

This disease has a very poor prognosis and 85% of patientsdie within a year of diagnosis. Cure is exceptionally rareand the primary aim of treatment is local control.

DIAGNOSIS

Core or open biopsy is the most appropriate investigationas FNAB will often be unhelpful. The particular object ofthe biopsy is to distinguish anaplastic carcinoma frommedullary carcinoma and from lymphoma. Immuno-cytochemistry may be needed to achieve a diagnosis.


CT or MRI give excellent information on local extensionof tumour.

TREATMENT

All patients diagnosed with anaplastic thyroid cancershould be reviewed by the Cancer Centre designatedspecialist multidisciplinary team.There is no consistent evidence that radiotherapy

or chemotherapy is useful, although radiotherapy may aid local control. Hyper-fractionated radiotherapywith doxyrubicin as a sensitiser may be more effective.Palliative resection of the tumour should be considered but is not normally feasible or useful unless the tumour is less than 5 cm in diameter. Tracheostomyshould be avoided if possible, tracheal stents should beconsidered in patients with airway obstruction.

2.4 THYROTOXICOSIS

Surgery for thyrotoxicosis can be technically demandingand should be performed by endocrine surgeons withappropriate training and organisational support. Patientsshould be treated by a team which includes anendocrinologist and an anaesthetist with appropriatetraining and experience of thyroid anaesthesia.A decision to recommend surgical management of

thyrotoxicosis should be made jointly by a surgeon and anendocrinologist or physician experienced in themanagement of thyroid disease. The treatment options ofanti-thyroid drugs, radioactive iodine ablation (RAI) andsurgery must be discussed with patients, and informedconsent taking account of patient preference must beobtained – see Section 6.2.

DIAGNOSIS

The diagnosis is based on the clinical features ofhyperthyroidism with additional specific features inGraves’ disease. Serum levels of free T4 and TSH must bemeasured in all patients. The free T3 level is mandatoryonly if there is a suppressed TSH and normal or minimallyelevated T4 level. Measurement of serum anti-body levelsis recommended. When the possibility of toxic uninodularor multinodular goitre or toxic adenoma exists, an isotopescan to localise area(s) of hyperactivity is indicated. Whenthe biochemical diagnosis is borderline, and in children,neonates and pregnant women, more detailed assessmentby an endocrinologist is recommended.

INDICATIONS FOR SURGERY

There are no fixed indications for surgery as the preferredtreatment of thyrotoxicosis. Normally surgery isconsidered only after failed medical treatment in the young(particularly adolescents) and in women who wish to, ormay become, pregnant within two years of radioiodinetreatment. Surgery also has a role in the management of thelarge toxic goitre.


Patients undergoing surgery for thyrotoxicosis should be

euthyroid or effectively ‘beta blocked’ to eliminate the riskof a thyrotoxic crisis. The following regimens can becombined if required.* A titrated dose of antithyroid drugs to normalise serum

levels of T3, T4 and TSH.

* A block and replace regimen of a large dose of anti-thyroid drug and replacement thyroxine.

* The effects of sympathetic over-activity may be blockedwith an appropriate beta blocking drug.

* Oral iodine for ten days before surgery in Graves’disease has been shown to reduce blood flow in thethyroid and may be considered.

Preoperative discussion with the patient should outline theobjectives of the operation taking into account familyplanning, social circumstances, compliance withmedication, ophthalmopathy and patient preference. Thelikely effect of surgery and the requirement forpostoperative thyroxine replacement and calcium/VitaminD supplements must be explained.

SURGERY

The surgery must be performed with a view to achievingthe preoperative objective and minimising surgicalmorbidity (avoidable injury to the recurrent and superiorlaryngeal nerves and conservation of functioningparathyroid tissue). Total/sub-total thyroidectomy isrecommended. Routine DVT chemoprophylaxis is notrequired, but mechanical DVT prevention should be used.


Facilities to deal with acute post-operative airway andmetabolic problems must be available. The serum calciumshould be checked after bilateral thyroid lobe resections.When pre-operative preparation includes beta blockadethis must be continued for 7 days post-operatively.Temporary early postoperative hypocalcaemia is common

after surgery (up to 30% patients) for thyrotoxicosis. Thismust be identified but requires treatment only if severe.Serum calcium should be measured within the first 24hours after surgery and regularly thereafter until normallevels are achieved by spontaneous recovery or institutionof calcium and/or vitamin D therapy.Following complete ablation of thyroid function,

thyroxine replacement must be instituted before thyroidfailure develops. The follow-up of patients after surgery toconserve function should continue until a stable euthyroidstate is achieved. Such patients may develop latehypothyroidism, the likelihood and timing of this is notpredictable. Long term monitoring of thyroid function isrecommended in these patients.

OPHTHALMOPATHY

Patients should be warned that surgery does not have apredictable effect on eye signs or prevent futuredevelopment or progression. Total thyroidectomy may, insome patients, favourably influence the course of


ophthalmopathy. Progressive eye signs may requirereferral to a specialist surgeon for treatment.

SURGICAL APPROACH TO THE THYROID GLAND

The standard approach for the thyroid is via an openoperation through a “collar” incision. Minimally invasivetechniques to remove the thyroid gland are beingdeveloped in several centres globally, and when a surgeonhas had specific training in this technique this may beappropriate. Patients should discuss options for the surgicalapproach with their surgeon and come to a joint decisionon the final procedure taking into account availableexpertise and the underlying thyroid disease.

SURGICAL TREATMENT OF THE PARATHYROID GLANDS

3.1 PRIMARY HYPERPARATHYROIDISM

Although some patients are genuinely ‘asymptomatic’ atpresentation, a full history will usually uncover symptomsthat may be due to Primary Hyperparathyroidism (HPT).The surgeon has a responsibility to ensure that alternative

causes of hypercalcaemia have been excluded.A family history must be taken to identify familial

hyperparathyroidism, multiple endocrine neoplasia types Iand II or familial hypercalcaemic hypocalciuria (FHH).


A liberal approach to surgery for patients with HPT isrecommended as there are no clear means to predict whichpatients will deteriorate if left unoperated upon. There is equivalent benefit from surgery in patients with symptomatic and with ‘asymptomatic’ mildhypercalcaemia. Patients aged 70 or less have a highermortality with untreated disease. The increased risk ofdeath decreases after successful parathyroid surgery.Successful operation improves reported functional healthstatus and quality of life. Cardiac changes have beenshown to be reversible after treatment of asymptomaticdisease. Symptoms of depression and anxiety may bereversed. Loss of bone mineral content is partiallyreversible.

INVESTIGATION

The biochemical diagnosis of HPT requires elevated levelsof corrected serum calcium and an intact parathyroidhormone level that is raised or inappropriate for thecalcium reading. Total urinary calcium or fractionalurinary calcium excretion may be helpful in borderlinecases. Normocalcaemia does not exclude hyperpa-rathyroidism. Hypocalciuria (< 2 mmol/day) shouldprompt the diagnosis of FHH.

For an experienced surgeon, when full cervicalexploration is performed, preoperative localisation ofparathyroid glands does not improve the likelihood of cureat first time neck surgery. In this setting objective evidenceof a benefit from routine scanning in terms of efficacy,

safety, cost effectiveness and treatment has not beenestablished. If preoperative localisation is considerednecessary the investigations of choice are 99Tc Sestamibiscanning, and high-resolution ultrasonography, and thiswill be required if a “focused” approach and limited neckdissection is to be performed.

SURGERY

The patient should receive an information sheet andconsent form specific to surgery for HPT and should havethe opportunity to discuss these with the operating surgeonprior to the operation – see Section 6.5.Surgery will result in normocalcaemia in excess of 95% of

patients with minimal morbidity. Unilateral neckexploration, whether or not aided by preoperative imagingstudies and minimally invasive parathyroid surgery (videoassisted or probe-guided unilateral approach) are feasible ,and these techniques can produce equivalent results tobilateral neck dissection. Approximately 50% of patientswill not be suitable for a focused approach because ofdiscordant scans or coincidental thyroid disease.In single gland disease the abnormal parathyroid gland

should be removed. If multiple gland enlargement is foundonly enlarged glands should be removed. If 4 large glandsare identified a remnant of one should remain in situ andshould be marked in case subsequent re-exploration isnecessary.The success of parathyroidectomy may be confirmed in

the majority of cases by the use of intra-operative PTHassay techniques. If excision has been effective, the PTHshould fall to less than half the pre-operative value withinfifteen minutes of excision, and should be in the normalrange. False positive results can occur, but are rare.Biopsy of normal glands is associated with increased

incidence of postoperative hypocalcaemia. When abnormalparathyroid tissue cannot be identified, normal parathyroidglands should not be removed. Routine DVT chemo-prophylaxis is not recommended but mechanicalprevention is advised.Patients with familial HPT should be treated in specialised

centres because different strategies are required for MEN I,II and Familial HPT. In familial syndromes the surgeonmust decide whether to perform a subtotal parathy-roidectomy (leaving a remant in the neck) and cervicalthymectomy, or a total parathyroidectomy withthymectomy and autotransplantation of parathyroid tissue.

PATHOLOGY

Intraoperative frozen section examination can be used toconfirm the removal of parathyroid tissue but cannot berelied upon to distinguish between hyperplasia andadenoma. The use of paraffin-embedded sections of theparathyroid gland may similarly prove difficult todistinguish adenoma form hyperplasia.


Serum calcium should be checked within the first 24 hoursafter surgery and subsequently if abnormal.Patients treated successfully for solitary adenoma should

have a serum calcium checked at one year and may be


discharged. Long-term follow up is recommended forpatients with multiple gland disease.

RECURRENT OR PERSISTENT HPTReoperative parathyroid surgery requires a multi-disciplinary approach and should be managed by aspecialist team in a centre with appropriate facilities. Themanagement will normally include reconfirmation of thediagnosis including a review of the original histopathologymaterial. Extensive attempts to localise the abnormalgland/s should be made with the object of achievingconcordance in two or more different test modalities. Theclinical indications for operation should be reappraised.

3.2 RENAL HYPERPARATHYROIDISM(SECONDARY OR TERTIARYHYPERPARATHYROIDISM)

Renal Hyperparathyroidism (RHPT) is one facet of amultisystem disease and patients should therefore only beaccepted for surgery at the recommendation of a consultantNephrologist or consultant Endocrinolgist. Patients shouldbe treated within a multispecialty environment wherecontinuing nephrological care and dialysis is availableduring the admission for surgery.


The presence of RHPT is not of itself an indication forsurgery. Surgery is normally only indicated in patientsrefractory to medical treatment who have very high levelsof serum calcium or PTH or complications of RHPT, inparticular bone disease, bone pain, soft tissue calcification,pruritus, unexplained myopathy or progressive vascularcalcification. Aluminium toxicity must be excluded as acause for symptoms.The decision to refer for surgery will require a

longitudinal review of symptoms, serum calcium, PTH andmeasures of bone metabolism, taken in the context of thepatient’s general condition and the effect of dialysis andmedications on the biochemical results.Routine imaging of the parathyroid glands is not indicated

prior to a first operation.

PREOPERATIVE PREPARATION

Normocalcaemic patients should be pretreated withVitamin D. During the admission for surgery the patientshould be under the joint care of the surgical andnephrology teams. The anaesthetist should be experiencedin the care of patients in renal failure. There should beexplicit liaison concerning the timing of surgery in relationto concurrent nephrological care.The patient should receive an information sheet and

consent form specific to surgery for RHPT and shouldhave the opportunity to discuss these with the operatingsurgeon prior to the operation – see Section 6.4 (page 22).Routine DVT chemoprophylaxis is not recommended.

SURGERY

The operation should be conducted by a surgeonexperienced in parathyroid surgery. The operation shouldattempt to identify all parathyroid tissue. This willnormally involve the identification of at least fourparathyroid glands and a search for ectopic parathyroidtissue in the neck. Routine cervical thymectomy isrecommended.

OPERATIVE STRATEGIES INCLUDE:* Total parathyroidectomy with or without autografting of

parathyroid tissue.

* Subtotal parathyroidectomy.

Each of these procedures can achieve the requiredbiochemical and symptomatic benefits and all may beassociated with recurrence. There is currently no consistentevidence to indicate that one strategy is preferable but totalparathyroidectomy without reimplantation may be lesssatisfactory in patients expected to receive a renaltransplant. The cryopreservation of parathyroid tissue forpossible later implantation is an option in units withspecific experience of this technique.


Postoperative hypocalcaemia may be more profound andsymptomatic than after surgery for PHPT and adjustmentsmay be needed to dialysis regime in response to this. Themajority of patients will require vitamin D and Calciumsupplementation.

RECURRENT OR PERSISTENT DISEASE

Detailed attempts at imaging are imperative before anyreoperation to establish whether the cause of excessivePTH is located in the neck, from an ectopic parathyroid orfrom hyperfunction of any autografted tissue. ReoperationMUST be carried out by an experienced endocrinesurgeon.

SURGICAL APPROACH

Open neck exploration of the neck is a well recognisedapproach with constantly good results in the hands ofexperienced endocrine surgeons.A “focused” approach following imaging of the

parathyroids my permit a smaller surgical scar and can beopen or using minimally invasive techniques (MI). MIsurgery should only be performed by those surgeonsexplicitly trained in the procedure, (and will probably beapplicable in no more than 50% of patients).

4. SURGICAL TREATMENT OFDISEASES OF THE ADRENAL GLAND

INTRODUCTION

Adrenal pathology requiring surgery is rare. Disorders ofadrenal function are often complex and the involvement ofan experienced endocrine team supported by sophisticated


clinical biochemistry and radiology is essential to secure areliable diagnosis. Successful surgical management isdependent on expert preoperative therapeutic preparationand skilled anaesthetic care, especially for patients withphaeochromocytoma. In practice the whole range ofrequired expertise is only likely to be found in a Regionalcentre to which most patients should be referred. The commonest diseases of the adrenal glands that require

surgical management are: * Hypercortisolism – ACTH independent – due to

adrenocortical adenoma (Cushing’s syndrome).

* Primary hyperaldosteronism due to adrenocorticaladenoma (Conn’s Syndrome).

* Phaechromocytoma.

* Incidentally discovered adrenal tumours,(‘incidentaloma’).

* Adrenocortical carcinoma.

The diagnosis of adrenal hyperplasia secondary toCushing’s disease or ectopic ACTH syndrome is notstraightforward and such patients may require multipleinvestigations under the endocrine medical team. Ifpituitary surgery and bronchopulmonary surgery fail,bilateral adrenalectomy may be indicated.There are other rare indications for surgical management

of adrenal disease such as metastatic disease and tumoursproducing sex hormones but these are not addressed inthese guidelines.

INVESTIGATIONS:

CUSHING’S SYNDROME SECONDARY TO

ADRENOCORTICAL ADENOMA

These patients have the clinical stigmata of Cushing’ssyndrome and the following biochemical abnormalities:high levels of urinary free cortisol, loss of diurnal rhythmof plasma cortisol, an abnormal dexamethasonesuppression test. The level of ACTH in the blood issuppressed. An adrenal mass is identified on a CT or MRIscan, 5 mm cuts are taken after enhancement withintravenous contrast. Typically the contralateral adrenal issuppressed, reflected in a smaller size on imaging.

PRIMARY HYPERALDOSTERONISM – ADRENOCORTICAL ADENOMA – CONN’S SYNDROME.Investigation will classically reveal hypokalaemia,inappropriately raised urinary potassium, a high plasmaaldosterone and a suppressed renin level. The aldosteronelevel does not suppress when the intake of sodium chlorideis increased and it is unaffected by posture. Normalindividuals typically increase their aldosterone levelsmarkedly (3-4 times) when recumbency is followed byseveral hours of activity. Those with Conn’s tumour showno change from this pattern whereas patients withidiopathic hyperaldosteronism – a bilateral nodularhyperplastic condition show a modest increase (30%).

Serial 3 mm CT (or MRI) scans will identify the majorityof Conn’s tumours arising in the cortex of one adrenal.Attenuation is not improved by intravenous contrast.Occasionally adrenal scintiscanning or selective venoussampling is required to lateralise the disease, often withACTH stimulation.

PHAEOCHROMOCYTOMA

Although the majority of patients have the classical triad ofheadaches, palpitations and hyperhidrosis with sporadicbouts of hypertension, fifteen percent of phaeochromo -cytomas are clinically silent and only declare themselvesas an abdominal mass on routine scanning or in response toanaesthesia or surgery for an unrelated condition. In somethere will be family history of phaeochromocytoma orMultiple Endocrine Neoplasia 2 or Von Hippel-Lindaudisease. The absence of a family history does not precludethe patient being the index case of a new mutation. In patients suspected of the diagnosis of phaeochromo-

cytoma, 24 hour total urinary metanephrines andcatecholamines are measured. Where the combined urinarycatecholamines are measured and are raised, aphaeochromocytoma is confirmed in more than 95% ofpatients. Localising an extra adrenal parganglioma is bestachieved with whole body scanning using MIBG labelledwith 123I or 131I and MRI. MRI is better than CT atdetecting extra adrenal paraganglioma and distinguishesphaeochromocytomas from the surrounding structureswithout the need for intravenous contrast. Malignant change in a phaeochromocytoma is only certain

where overt local invasion and distant metastases areobserved. Neither of these may be evident at the time ofinvestigation and surgery. Malignancy cannot be excludedon histology, long-term follow up is therefore advised.

INCIDENTALOMA

This term includes all tumours which are a chance findingon abdominal scanning by whatever modality whenadrenal disease was unsuspected. Approximately 1-3% ofabdominal CT scans reveal such adrenal tumours. Half ofthem are metastases from known primaries and a third arecortical adenomas. The remainder comprise stromaltumours such as myelolipoma, haemangioma andlymphangioma. A full clinical history may reveal previously unrecognised

symptoms of adrenal over-activity. Even if there are nosymptoms to indicate hyperfunction, a basic biochemicalscreen should be undertaken to exclude a functioningadrenal tumour.Assessment of serum cortisol and potassium and urinary

metanephrines and catecholamines is recommended. If afunctioning lesion is discovered, surgical removal willusually be appropriate but incidentalomas less than 3 cm indiameter can safely be observed with repeat CT scanningto monitor any increase in size. Surgical removal isindicated if growth is rapid or if the diameter exceeds 3cm. Needle biopsy is only indicated to confirm metastaticdisease in a patient with a history of primary malignancyelsewhere but no other evidence of metastases.


ADRENOCORTICAL CARCINOMA

These tumours are typically bulky, greater that 1.5 cm indiameter and invade locally with early spread to the liver,regional lymph nodes and the lungs. Half the tumours arephysiologically active with hypercortisolism and/orexcessive androgen production. Weight loss and anaemiasignal malignancy and an MRI scan provides the mostcomplete assessment of operability. Measurement ofdihydroepiandrosterone sulphate levels may assist in thediagnosis.

PREOPERATIVE PREPARATION

Adrenal surgery is a major procedure even whenundertaken laparoscopically. Cardiac and respiratoryfunction should be optimised. Anaemia and any electrolyteimbalance should be corrected and any intercurrentinfection treated. Patients undergoing open or laparoscopicsurgery should receive thromboprophylaxis.

HYPERCORTISOLISM: CUSHING’S DISEASE AND CUSHING’S SYNDROME

Prophylactic antibiotics and thromboprophylaxis areparticularly required for this group. Anticipating thedramatic fall of circulating cortisol after bilateraladrenalectomy and unilateral adrenalectomy where thecontralateral adrenal is likely to be suppressed, 100 mg ofparenteral hydrocortisone hemisuccinate is given in theanaesthetic room and again on completion of the operation.

CONN’S DISEASE

Spironolactone 200-400 mg daily can be given for fourweeks to stabilise hypertension and reverse hypokalaemia.

PHAEOCHROMOCYTOMA

Blockade of alpha-adrenergic receptors, (with doxazosin orphenoxybenzamine) is essential prior to surgery. Thedosage and duration of treatment is highly individualisedaccording to the severity of the disease and patients willsometimes require admission to stabilise hypertension andexpand the intravascular volume. This is reflected in a fallin the haematocrit and an increase in the body weight.Patients invariably experience some postural hypotensionwith a dry mouth and a degree of sedation. Wheretachycardia or arrhythmias develop a beta-blocker such asatenolol may be given but only when alpha blockade iscomplete.

The anaesthetist involved in the surgery ofphaeochromocytoma MUST be familiar with thecomplexities of the anaesthesia for such patients. Theanaesthetist should be closely involved in the preoperativepreparation of the patient. The technical details ofappropriate anaesthesia for these patients is outside thescope of these guidelines.

SURGERY

Solitary tumours should normally be treated by totalremoval of the affected adrenal gland. Where theunderlying pathology is the adrenal hyperplasia ofCushing’s disease with a continuing source of over

secretion of ACTH, all adrenal tissue must be removed.Subtotal excision of an adrenal gland or reimplantation ofadrenal tissue is not of proven value and should only beundertaken as part of an ethically approved, scientificstudy.Benign tumours in which there is no suspicion of

malignancy can normally be removed laparoscopically bya transperitoneal or retroperitoneal route. The surgicalapproach to large tumours (>6 cm) will depend upon theexperience of the surgeon, the patient’s habitus, and thesize of the tumour. There is no longer any requirement thatphaeochromocytomas should be removed by thetransperitoneal route to allow palpation of the contralateraladrenal bed. The superiority of one technique ofadrenalectomy over the other has not yet been determined,but the laparoscopic approach is rapidly gainingpopularity.


Patients undergoing bilateral adrenalectomy requirelifelong adrenal replacement medication. In the immediatepostoperative phase this will be by bolus iv administrationof Hydrocortisone hemisuccinate repeated six hourly untilthe patient can be switched to oral replacement. Thisshould be by a locally agreed protocol but as a guideline 20mg of hydrocortisone is taken in the morning and 10 mg ofhydrocortisone in the evening. The need forfludrocortisone is determined by the serum potassiumlevel, doses range from 50-200 µg per day. It is vital thatpatients appreciate the importance of maintaining theirreplacement therapy and the need to increase the steroiddose if infection or stress arises. All patients should be given a ‘steroid card’ indicating

their steroid doses, hospital contact details and advice.Patients undergoing unilateral adrenalectomy for a cortisolsecreting adenoma will also require cortisonepostoperatively as the remaining adrenal will have beensuppressed. The suppressed adrenal may require up to 18months to recover and cortisone should not bediscontinued until that recovery has been documented by aSynacthen test.Occasionally aldosterone secreting tumours also secrete

cortisol and where this is detected suppression of thecontra lateral adrenal should be anticipated by givingcortisone replacement pre and post adrenalectomy as forpatients with Cushing’s syndrome.


5. SURGICAL TREATMENT OF THE ENDOCRINEPANCREAS

Pancreatic endocrine tumours (insulinoma and gastrinoma)are rare and require complex diagnostic and preoperativeassessment. Surgical decision making and operativetechnique require specific experience of these conditionswhich should therefore be treated by a specialist endocrineteam with the requisite experience. This will normallyrequire referral to a regional centre.

5.1 INSULINOMA

DIAGNOSIS

A full clinical assessment must be made in an endocrineclinic. Particular care must be taken to identify familialdisease and exclude other endocrinopathies. Regionalgenetics units should be consulted in familial syndromes.

BIOCHEMICAL

* The demonstration of a low fasting blood glucose and ahigh insulin.

* A 72 hour fast to provoke and unmask hypoglycaemia. Ablood sugar below 2 mmo1/1 and an inappropriatelyraised insulin greater than 16 mU/1 is usually required.

* A high level of pro-insulin suggests malignancy.

* A high titre of insulin antibodies and low C peptidesuggests a factitious hypoglycaemia due to exogenousinsulin administration.

* A gut hormone profile, serum calcium, PTH andprolactin should be measured to identify other endocrineadenopathies.

LOCALISATION

Precise localisation of an insulinoma is not essential beforelaparotomy is performed. A variety of localisationprocedures are available which include endoscopicultrasound, CT, MRI and octreotide scanning.Approximately 30% of insulinomas will be identified byOctreoscan. Endoscopic ultrasound is currently the mosteffective localisation procedure. Venous sampling andselective arterial calcium infusion stimulation testing isconducted in some centres.

SURGERY

Once the diagnosis has been established almost all patientsare submitted to surgery and pancreatic exploration even inthe absence of preoperative localisation of the tumour.Only those patients unfit for surgery are treated withdiazoxide or octreotide.Even though only 10% of insulinomas are malignant, liver

secondaries are excluded at laparotomy by palpation andintraoperative ultrasound. The pancreas is fully mobilisedin order to permit careful palpation from head to tail.Intraoperative ultrasound should be used to localise thetumour and demonstrate its relationship to importantvascular structures and the pancreatic duct. Most

insulinomas are treated by enucleation but lesions in thetail of the pancreas are best treated by distalpancreatectomy. When the tumour is closely related to thepancreatic duct a distal pancreatectomy is a saferprocedure. Lesions in the head of the pancreas should beenucleated and a Whipple’s procedure is rarely necessary.Frozen section histology is used to confirm the neuro-

endocrine nature of the lesion. A spontaneous rise in bloodglucose will demonstrate success but failure to note such arise should not be taken to indicate failure. If no tumour isfound at operation, blind distal pancreatectomy is NOTrecommended.

SURGICAL STRATEGY FOR MEN 1In this familial disorder the pancreatic lesions are multipleand require treatment by enucleation of those situatedwithin the head of the organ and by a generous distalpancreatectomy as far as the portal vein.


The patient is best managed for the first few hours in ahigh dependency unit with regular monitoring of bloodglucose.Unresectable primary disease or hepatic metastases should

be managed medically with octreotide, hepaticembolisation or resection.

5.2 GASTRINOMA(ZOLLINGER-ELLISON SYNDROME)

DIAGNOSIS

Full clinical assessment must be made in an endocrineclinic. Particular care must be taken to identify familialdisease and exclude other endocrinopathies.

BIOCHEMICAL

* High serum Gastrin when atrophic gastritis has beenexcluded by biopsy (Atrophic gastritis is thecommonest cause of hypergastrinaemia).

* Secretin stimulation test (2U/kg body weight) is requiredto confirm the diagnosis of gastrinoma and distinguish itfrom antral G-cell hyperplasia.

* Measurement of gut hormone profile, calcium, PTH andprolactin to exclude MEN 1.

LOCALISATION

Recommended tests include ultrasound, CT, MRI,octreotide scintigraphy and endoscopic ultrasound.Selective arterial calcium stimulation with venoussampling for gastrin (Imamura test) is a helpful method forregionalisation but not true localisation of gastrinoma.

SURGERY

Patients with confirmed Zollinger-Ellison syndrome mayhave sporadic disease or MEN 1 syndrome. Both groupsshould be treated by active surgical intervention if hepaticmetastatic disease has been excluded. Elective totalgastrectomy or vagotomy is NOT indicated.


All patients should be treated with proton pump inhibitorsup to the time of surgery.

SPORADIC GASTRINOMA

The primary tumours are frequently located outside of thepancreas, within the duodenal or even jejunal mucosa. Thepancreas and duodenum should be fully mobilised,carefully palpated and also examined by intra operativeultrasound. In sporadic disease 30-40% of primary tumourswill be within the duodenum and frequently accompaniedby lymph node metastasis. Identification of the duodenal wall lesion can be aided by

endoscopic trans illumination as well as careful palpation,the latter being performed after a generous duodenotomy.These lesions are usually too small to be identified byultrasound. Once the primary lesion has been identified either within

the gut or pancreas, it is excised and all adjacent lymphnodes meticulously cleared. If a primary tumour has been located in sporadic

Zollinger-Ellison syndrome, no other search for additionaltumours is required. Frozen section histology will confirmthe neuro-endocrine nature of the lesion.

MEN 1 SYNDROME

HPT should be excluded and, if present, treated first. Acomplete pancreatic exploration for gastrinoma similar tothat performed for sporadic disease is required andexcision of any lesion within the wall of the gut,enucleation of lesions within the head of the pancreas, anda completion distal pancreatectomy performed. Multiple neuro-endocrine tumours will inevitably be

present and more than 60% will be within the wall of theduodenum. Duodenotomy is therefore mandatory. AWhipple’s resection of the head of pancreas is rarelyrequired. All draining nodes are resected and subjected to histology.


Initial recovery should be in a high dependency unit. Thepatient should remain on proton pump inhibitors as there islikely to be significant gastric hypertrophy and continuinghypersecretion of acid. Long term follow up and regularreview in out patient clinic is required. After three to four months the proton pump inhibitor

should be stopped and the patient re-evaluated bymeasurement of fasting and secretin stimulated gastrinlevels. In persistent or recurrent disease the patient shouldremain on proton pump inhibitors. Unresectable primary disease or hepatic metastases

should be managed medically with octreotide and protonpump inhibitors. Hepatic embolisation or resection isoccasionally indicated. Chemotherapy is not recommended.Operation in the presence of biochemical abnormality but

no identified lesion on imaging is increasingly advised inconfirmed MEN I. In this setting distal pancreatectomy anda search for lesions in the duodenum and head of thepancreas with enucleation as necessary is advised.


6. PATIENT INFORMATION SHEETS

* 6.1 THYROIDECTOMYFOR BENIGN NODULAR DISEASE OF THE THYROID

* 6.2 THYROTOXICOSIS (OVER ACTIVE THYROID)

* 6.3 ADVICE TO PATIENTS LEAVING HOSPITAL AFTERADMINISTRATION OF 131-IODINE

* 6.4 RENAL HYPERPARATHYROIDISM (RHPT)

* 6.5 PRIMARY HYPERPARATHYROIDISM (HPT)


INFORMATION SHEET FOR PATIENTS

6.1 THYROIDECTOMYFOR BENIGN NODULAR DISEASE OF

THE THYROID

IntroductionThis sheet is intended to tell you about the thyroid gland

and give you information about the operation ofthyroidectomy. Your surgeon will explain to you thereason for recommending surgery as treatment for yourthyroid gland. The surgeon will also discuss whether inyour case it is planned to remove all of the thyroid or onlypart of it.

The Thyroid GlandThe thyroid gland produces a chemical substance (a

hormone) called thyroxine. This hormone circulates aroundthe body in the blood and controls the speed at which thebody’s chemical processes work. The normal thyroid hasconsiderable spare capacity for making thyroxine, and sonormally removal of as much as half of the gland can beundertaken without any need to give thyroxine replacementin the form of daily tablets after the operation. If howeverthe whole thyroid has been removed you will need to takethyroxine for the rest of your life. Very close to the thyroid glands are four tiny glands called

parathyroid glands, each not much bigger than a grain ofrice. These produce a hormone, which controls the level ofcalcium in your body. The parathyroid glands are normallyleft in place when the thyroid gland is operated upon buttheir function may be affected by the operation on thethyroid; there is more information about this later in thisdocument.

SurgeryThe operation requires a general anaesthetic and a stay in

hospital, which is normally between 2 and 4 days. Accessto the thyroid obviously requires that the surgeon make anincision in the neck. This is made a couple of fingerbreadths above the top of the breastbone. It is made in askin crease or following the “grain” of the skin. This collarincision is symmetrical even if the thyroid abnormality isonly on one side. Most thyroidectomy incisions heal toproduce a very satisfactory scar. At the end of theoperation the surgeon may consider it appropriate to leavea small “drain” tube in the neck. This will normally beremoved on the first or second day after surgery. In somethyroid operations it is necessary to remove some of thelymph glands from the neck. The absence of these glandsdoes not normally produce any problems; if your surgeonexpects to remove lymph glands it will have beendiscussed with you.

Possible complicationsMost thyroid operations are straightforward and associated

with few problems. However all operations carry riskswhich include postoperative infections (e.g. in the wound

or chest), bleeding in the wound and miscellaneousproblems due to the anaesthesia, but these are very rare.Bleeding in the wound can be a serious problem if it occursbut the chance of a significant bleed needing you to returnto the operating theatre within a day or two after youroperation to clear out the blood is small (in the region of1`in 50).

Scar:The scar may become relatively thick and red for a few

months after the operation before fading to a thin whiteline. Very rarely some patients develop a thickexaggerated scar but this is uncommon.

Voice Change:It is impossible to operate on the neck without producing

some change in the voice; fortunately this is not normallydetectable. A specific problem related to thyroid surgery isinjury to one or both of the Recurrent Laryngeal Nerves.These nerves pass close to the thyroid gland and controlmovement of the vocal cords. Injury to these nervescauses hoarseness and weakness of the voice. The nervemay not work properly after thyroid surgery due tobruising of the nerve but if this should occur, it recoversover a few weeks or months. Rarely, the nerve may bepermanently injured and the nerve function will notrecover. The External Laryngeal Nerve may also be injuredand this results in a weakness in the voice although thesound of the voice is unchanged. Difficulty may be foundin reaching the high notes when singing, the voice may tiremore easily and the power of the shout reduced. Carefulsurgery reduces the risk of permanent accidental injury to avery low level but cannot absolutely eliminate it. Injury toboth recurrent laryngeal nerves is extremely rare but is aserious problem and may require a tracheostomy (tubeplaced through the neck into the windpipe).

Low blood calcium levels:Patients undergoing surgery to the thyroid gland are at risk

of developing a low calcium level if the four tinyparathyroid glands which control the level of calcium inthe blood stop working after the operation. It is normallypossible to identify and preserve some if not all of theseglands and so avoid a long-term problem. Unfortunatelyeven when the glands have been found and kept they maynot function. If this happens then you will require to takeextra calcium and/or vitamin D on a permanent basis. Therisk of you needing long term medication because of a lowcalcium level is small (about 1 in 50). It is quite commonto require calcium and/or vitamin D tablets for a fewweeks or months after the operation.

Thyroid function:If it has been decided to remove all the thyroid gland then

you will require lifelong replacement of thyroxine.Fortunately this is a straightforward once a day regimenwith little requirement for adjusting dosage. There is aprescription charge exemption for patients requiringthyroxine tablets so you will not have to pay for these (orany other tablets as the law currently stands). If most, but


not all, of the thyroid gland is removed then in the earlyweeks after the operation the remaining thyroid may notproduce enough thyroxine and you may requirereplacement tablets temporarily until the retained thyroidproduces enough hormone itself. This will be monitored.

Swallowing difficulty:Usually swallowing is improved following thyroid

surgery, especially for large goitres or those which haveextended down into the chest, but occasionally some milddifficulty may develop or be persistent. Similarly, if youare experiencing any difficulty with your breathing beforethe operation, then this may also be eased.

We wish to emphasise that these potential side effects andcomplications are unusual, but we believe it is essential totell you about these rather than have you develop acomplication without having been forewarned. If you areunclear about the topics in this sheet or if you are unclearabout any other details of your operation please ask one ofthe surgical team.

I confirm that I have read the above and have discussedany queries with the surgical team.

Name ........................................ Signature ..................................... Date .......................

Note: If you search the Internet for information on thissubject you should remember that some sites will describecalcium levels using different units of measurement.Additionally many sites are in effect advertising forpatients and may propose untried or non standardprocedures and treatments, so beware and discuss what youread with your doctors.


INFORMATION SHEET FOR PATIENTS

6.2 THYROTOXICOSIS (OVER ACTIVE THYROID)

Investigations have shown you to have an overactivethyroid gland. Three treatment options are available forthis:-

* Antithyroid Drugs

* Radioiodine

* Surgery.

Most patients will need antithyroid drugs initially tocontrol the thyroid overactivity. These drugs may becontinued for around 18 months to allow the thyroid torecover spontaneously but in many cases such recoverywill not occur and a more permanent treatment will beneeded using radio-iodine or surgery. Often the illness willrecur even after a full length course of antithyroid drugsand in these circumstances treatment with radioiodine orsurgery will normally be advised.

Antithyroid drugs:These are relatively slow acting and several months after

withdrawal of treatment a significant number of patientswill experience recurrence of the problem. There may beside effects associated with these drugs which may requirethem to be stopped.

Radioactive Iodine:This is probably the simplest option for treating most

overactive thyroid glands. It requires swallowing a capsulecontaining radioactive iodine which is taken up by thethyroid gland. The radioactivity destroys the thyroid cellsthat are causing the overactivity. Most patients aresuccessfully treated with only one course of treatment butsome require more than one. The major side effects of thistreatment is that you have to keep a distance away fromother people, particularly pregnant women and youngchildren for several days until the level of radioactivitydrops. This usually takes 2 to 3 weeks. (See advice sheetbelow). Radioactive iodine therapy is not recommended for young

women who are or wish to become pregnant within thenext few months. You must not take radioactive iodine ifyou are currently pregnant or breast feeding. There is noevidence of long-term harm from taking radioactive iodinealthough most patients who take it will develop an under activethyroid sooner or later and require to take thyroid tablets.

Surgery:Surgery is a suitable option for many patients with an

overactive thyroid gland when antithyroid drugs do notwork and a decision must be made between an operation

and radioactive iodine. The advantages of an operation arethat it removes an enlarged gland (goitre) and eases anysymptoms caused by pressure of the gland on the otherneck structures. It rapidly cures the overactivity and canrestore normal function to patients for many years.However a substantial number of patients will have anunder active thyroid after the operation and other patientswill become under active with each passing year. For thisreason it is sometimes recommended that all or virtually allthe thyroid is removed and replacement thyroid hormone isstarted just after the operation. If some of the thyroid glandis left behind, then this can occasionally become overactiveagain in the future. Removing the whole of the gland hasthe great advantage of solving the problem once and for allwith no risk of recurrence of the overactivity and norequirement for careful follow-up provided the thyroidtablets are taken once a day for the rest of your life.

Preparation for surgery:When a decision has been made to proceed with surgery it

is important that the effects of thyroid over activity arecontrolled before hand. This requires you to take theprescribed medication up to the time of the operation. Ifyou have been prescribed a beta blocker (e.g. propranololor nadolol) you may need to continue to take these for afew days after the operation. Your doctors will advise youif this is necessary.

Possible complications:Most thyroid operations are straightforward and associated

with few problems. However all operations carry riskswhich include postoperative infections (e.g. in the woundor chest), bleeding in the wound and miscellaneousproblems due to the anaesthesia, but these are very rare.Bleeding in the wound can be a serious problem if it occursbut the chance of a significant bleed needing you to returnto the operating theatre within a day or two after youroperation to clear out the blood is small (in the region of1`in 50).


months after the operation before fading to a thin whiteline. Very rarely some patients develop a thick exaggeratedscar but this is uncommon.

Voice Change:It is impossible to operate on the neck without producing

some change in the voice; fortunately this is not normallydetectable. A specific problem related to thyroid surgery isinjury to one or both of the recurrent laryngeal nerves.These nerves pass close to the thyroid gland and controlmovement of the vocal cords. Injury to these nerves causeshoarseness and weakness of the voice. It is uncommon forthe nerve not to work properly after thyroid surgery due tobruising of the nerve but if this should occur, it recoversover a few weeks or months. The external laryngeal nervemay also be injured and this results in a weakness in thevoice although the sound of the voice is unchanged.Difficulty may be found in reaching the high notes when


singing, the voice may tire more easily and the power ofthe shout reduced. Careful surgery reduces the risk ofpermanent accidental injury to a very low level but cannotabsolutely eliminate it. Injury to both recurrent laryngealnerves is extremely rare but is a serious problem and mayrequire a tracheostomy (tube placed through the neck intothe windpipe).

Low blood calcium levels:Patients undergoing surgery to the thyroid gland are at risk

of developing a low calcium level if the four tinyparathyroid glands which control the level of calcium inthe blood stop working after the operation. It is normallypossible to identify and preserve some if not all of theseglands and so avoid a long-term problem. Unfortunatelyeven when the glands have been found and kept they maynot function. If this happens then you will require to takeextra calcium and/or vitamin D on a permanent basis. Therisk of you needing long term medication because of a lowcalcium level is small (about 1 in 50). It is quite commonto require calcium and/or vitamin D tablets for a fewweeks or months after the operation.

Thyroid function:If it has been decided to remove all the thyroid gland then

you will require lifelong replacement of thyroxine.Fortunately this is a straightforward once a day regimenwith little requirement for adjusting dosage. There is aprescription charge exemption for patients requiringthyroxine tablets so you will not have to pay for these (orany other tablets as the law currently stands). If most, butnot all, of the thyroid gland is removed then in the earlyweeks after the operation the remaining thyroid may notproduce enough thyroxine and you may requirereplacement tablets temporarily until the retained thyroidproduces enough hormone itself. This will be monitored.

Swallowing difficulty:Usually swallowing is improved following thyroid

surgery, especially for large goitres or those which haveextended down into the chest, but occasionally some milddifficulty may develop or be persistent. Similarly, if youare experiencing any difficulty with your breathing beforethe operation, then this may also be eased.

Pregnancy:Once the thyroid hormone levels are normal after surgery,

there is no reason not to become pregnant if desired. If youbecome pregnant during treatment with antithyroidmedications such as carbimazole or propylthiouracil, it isnot a major problem, but it is important to notify yourhospital doctor as soon as possible.

We wish to emphasise that these potential side effects andcomplications are unusual, but we believe it is essential totell you about these rather than have you develop acomplication without having been forewarned. If you areunclear about the topics in this sheet or if you are unclearabout any other details of your operation please ask one ofthe surgical team.


Name ........................................ Signature ..................................... Date .......................


PATIENT INFORMATION SHEET

6.3 ADVICE TO PATIENTS LEAVINGHOSPITAL AFTER

ADMINISTRATION OF 131-IODINE

These notes are to help you understand some of therestrictions that you will need to follow after receiving aradioactive treatment for an over active thyroid.

The radioactive treatment is prescribed for you and onlyyou will benefit from the treatment. The followinginstructions are to be adhered to in order to limit theamount of radiation to other people. Remember they havenot been prescribed the radiation and will receive nobenefit from it.

Make sure you understand the restrictions. There will beopportunities while at the hospital to ask any questions youmay have.

The Card:You will be given a card when the treatment is

administered. The card lists the restrictions and the numberof days for which the restrictions will apply.

With regards to children and pregnant women the cardsays:-

(a) Refrain from all close contactThis means – cuddling is not permitted. You should

generally keep a minimum distance of 1 metre (3 feet)away from a child (except for occasional very briefperiods). This degree of restriction should last for either 9or 15 days, depending on the activity given.

(b) Refrain from extended periods of close contactThis means – limited contact is permitted, but you shouldnot cuddle a child for more than 15 minutes per day andshould not sleep with a child or pregnant woman in thesame bed. This degree of restriction should last for either21 – 25 days depending on the activity given. Normalcontact can be resumed after this time.

Remember – occasional brief periods of contact withchildren or pregnant women will not be harmful, but youshould restrict your contact by observing the tworestrictions above.

In cases where you have sole responsibility for the careof a child, it should normally be recommended thatalternative arrangements be made for the childs care for upto 25 days. This should be discussed with the doctor atyour appointment at the hospital, before the treatment.

Travel – On leaving the hospital after the treatment thereare no restrictions on the use of seated private or publictransport provided the journey is less than 3 hours.

Spills – Please contact the hospital Nuclear MedicineDepartment if you should vomit or be incontinent of urinewith 24 hours of the treatment.

Returning to work – Return to work on the day followingtreatment. This advice may be different for people whowork close to others. If you work, please discuss yourwork with hospital staff.

Partners – Providing your partner is aware of the radiationand is not pregnant, you may sleep in the same bed.However there is a restriction if you have received thelarger activity treatment. Then you should have separatebeds for 4 days.



6.4 RENAL HYPERPARATHYROIDISM(RHPT)

The parathyroid glands are small glands usually situatedbehind the thyroid gland at the base of neck and whichproduce parathyroid hormone (PTH) which controls thelevel of calcium in the blood. The control of blood calciumlevels is important for the proper functioning of the brainand nervous tissue and the maintenance of healthy bones.There are normally four parathyroid glands which areusually situated close to the thyroid gland. Their functionis completely unrelated to that of the thyroid.In some patients with kidney disease a complex sequence

of events can cause the parathyroid glands to becomeoveractive and produce too much hormone. This leads toan excess of calcium in the blood, most of which is drawnfrom the bones which are thereby damaged. Some of thisexcess calcium may be deposited in other structures suchas blood vessel walls where it may cause damage. Thissequence of events is known as renal hyperparathyroidism(RHPT). RHPT may persist even when the originaldamage to the kidney as been corrected by dialysis or bytransplantation.The treatment of RHPT is by medication in the first

instance, but this is not always effective and sometimes itbecomes necessary surgically to remove all or most of theparathyroid glands. The operation is known asparathyroidectomy.

PARATHYROIDECTOMY

The technical details of the operation will be explained toyou by your surgeon. At the operation the surgeon will tryto locate all your parathyroid glands and will remove all ormost of them. If all are removed part of one may beimplanted into a forearm muscle. This procedure isundertaken so that if the overactivity of the parathyroidtissue recurs a further operation maybe necessary and itmay be easier to remove tissue from the arm than from theneck.

The Operation

Operations on the parathyroid glands are very safe butsometimes there are complications and this sectionsummarises these for you. If having read it there isanything that worries you and about which you would likefurther information please ask the surgical team.


months after the operation before fading to a thin whiteline. Very rarely some patients develop a thickexaggerated scar but this is uncommon.

Voice Change:It is virtually impossible to operate on the neck without

producing some change in the voice; fortunately this is notnormally detectable. A specific problem related toparathyroid surgery is injury to one or both of the recurrentlaryngeal nerves. These nerves pass close to the thyroidgland and control movement of the vocal cords. Injury tothese nerves causes hoarseness and weakness of the voice.The nerve may not work properly after parathyroid surgerydue to bruising of the nerve but if this should occur, itrecovers over a few weeks or months. Rarely, the nervemay be permanently injured and the function will notrecover. The external laryngeal nerve may also be injuredand this results in a weakness in the voice although thesound of the voice is unchanged. Difficulty may be foundin reaching the high notes when singing, the voice may tiremore easily and the power of the shout reduced. Carefulsurgery reduces the risk of permanent accidental injury to avery low level but cannot absolutely eliminate it. Injury toboth recurrent laryngeal nerves is extremely rare but is aserious problem and may require a tracheostomy (tubeplaced through the neck into the windpipe).

Other hazards:Most parathyroid operations are straightforward and

associated with few problems. However all operationscarry risks which include postoperative infections (e.g. inthe wound or chest), bleeding in the wound andmiscellaneous problems due to the anaesthesia, but theseare very rare. Bleeding in the wound can be a seriousproblem if it occurs but the chance of a significant bleedneeding you to return to the operating theatre within a dayor two after your operation to clear out the blood is small(in the region of 1`in 50).

Results of surgery

Operations to correct RHPT are intended to remove orreduce symptoms which you are having which may beattributable to the RHPT. You should discuss with yoursurgeon or renal physician the reasons why you have beenreferred for surgery and their expectations ofimprovement. Parathyroidectomy may be effective atcontrolling the RPHT and reducing future damage but maynot necessarily improve your current symptoms or restoredamaged bones, nor can it be expected to alter your needfor renal replacement therapies such as dialysis. In mostpeople the stimulus to parathyroid overactivity remainseven after successful surgery, but there is always a risk thatparathyroid tissue which has been left in your body mayenlarge and lead to recurrence of your symptoms. Aboutone patient in ten undergoing parathyroidectomy for RPHTwill require a further operation on the parathyroid glands inthe future. In other patients parathyroidectomy mayremove all functioning parathyroid tissue and you mayrequire continuing medical treatment to sustain a normalblood calcium level. It is not possible to predict in advancewhat the long term result of parthyroidectomy will be onyour blood calcium levels, but in the majority of patientsthe operation will be beneficial.




Name ................................... Signature ...................................... Date .......................



6.5 PRIMARY HYPERPARATHYROIDISM(HPT)

The parathyroid glands are small glands usually situatedbehind the thyroid gland at the base of the neck and whichproduce parathyroid hormone (PTH) which controls thelevel of calcium in the blood. There are normally fourparathyroid glands; although they are situated close to thethyroid gland their function is completely unrelated to thatof the thyroid. The control of blood calcium levels isimportant for the proper functioning of the brain andnervous tissue and the maintenance of healthy bones. Toomuch PTH leads to too high a level of calcium in the bloodand this can have various damaging effects, especially onthe skeleton and kidneys. One of the surgical team willhave discussed with you why it is necessary to remove oneor more of your parathyroid glands to control theoverproduction of PTH. Usually there is only oneabnormal gland but there may be two or more affectedglands. Parathyroid cancer is very rare and the abnormalityin the parathyroid glands is nearly always benign.

The Operation

During your operation the surgeon will attempt to find andremove the abnormal parathyroid gland or glands andidentify, inspect and possibly take samples from the otherparathyroid glands. Abnormal glands may not be found atthe time of operation in about one patient in twenty. Onereason is that the gland may be so small or hidden that itcannot be found or seen. This happens very rarely.Another reason may be that the gland lies not in the neckbut in the chest. If that is the case you may need anotheroperation at another time to remove it.Operations on the parathyroid glands are very safe but

sometimes there are complications and this sectionsummarises these for you.


months after the operation before fading to a thin whiteline. Very rarely some patients develop a thick exaggeratedscar but this is uncommon.

Voice Change:It is virtually impossible to operate on the neck without

producing some change in the voice; fortunately this is notnormally detectable. A specific problem related toparathyroid surgery is injury to one or both of the recurrentlaryngeal nerves. These nerves pass close to the thyroidgland and control movement of the vocal cords. Injury tothese nerves causes hoarseness and weakness of the voice.The nerve may not work properly after parathyroid surgerydue to bruising of the nerve but if this should occur, itrecovers over a few weeks or months. Rarely, the nervemay be permanently injured and the function will notrecover. The external laryngeal nerve may also be injured

and this results in a weakness in the voice although thesound of the voice is unchanged. Difficulty may be foundin reaching the high notes when singing, the voice may tiremore easily and the power of the shout reduced. Carefulsurgery reduces the risk of permanent accidental injury to avery low level but cannot absolutely eliminate it. Injury toboth recurrent laryngeal nerves is extremely rare but is aserious problem and may require a tracheostomy (tubeplaced through the neck into the windpipe).

Other hazards:Most parathyroid operations are straightforward and

associated with few problems. However all operationscarry risks which include postoperative infections (e.g. inthe wound or chest), bleeding in the wound andmiscellaneous problems due to the anaesthesia, but theseare very rare. Bleeding in the wound can be a seriousproblem if it occurs but the chance of a significant bleedneeding you to return to the operating theatre within a dayor two after your operation to clear out the blood is small(in the region of 1`in 50).

The Results of SurgeryFrom the situation of having too high a level of calcium

before the operation, the calcium often falls to quite a lowlevel shortly after the operation. This is because the otherglands have become lazy or under active. The other glandswill recover their normal function quite quickly but youmay require calcium and vitamin D tablets temporarilyafter the operation to boost the level of calcium in thebody. Rarely, the other glands may not recover and youwill need to take calcium and/or vitamin D tablets.Operations to correct HPT are intended to remove or

reduce symptoms which you are having which may beattributable to the HPT. You should discuss with yoursurgeon or medical doctor the reasons why you have beenreferred for surgery and their expectations of improvement.Parathyroidectomy may be effective at controlling the HPTand reducing future damage but may not necessarilyimprove your current symptoms.


Name ................................... Signed ..................................... Date ...........................



APPENDIX 1

TRAINING REQUIREMENTS

AND

CURRICULUM

FOR ENDOCRINE SURGERY


REQUIREMENTS FOR TRAINING INENDOCRINE SURGERY

LENGTH OF TRAININGOne year in a BAES recognised HST Training Unit.

Because of the rarity of some endocrine tumours it may beadvisable that trainees spend more than one year in such aunit if this is practical or possible. Flexible rotationsbetween regions may be required.

LOCATION OF TRAININGTraining should be undertaken in Units consisting of one

or more surgeons approved as endocrine surgical trainersby the BAES and the SAC in General Surgery.Approved endocrine surgical training Units will normallyconsist of:

* One or more surgeons with a declared interest inendocrine surgery.

* An annual operative throughput in excess of 50 cases* On site cytology and histopathology services* At least one consultant endocrinologist on site holding

one or more dedicated endocrinology clinics per week.* A Department of Nuclear Medicine on site.* On site MR and CT scanning facilities.

It is accepted that candidates may need to have access toother units to ensure some experience of specialisttechniques such as laparoscopic adrenal surgery.

THE SYLLABUS

The BAES believes that in addition to proper knowledgeand experience of the principles and practice of generalsurgery candidates offering a special interest in endocrinesurgery:

* Must have a firm grounding in the basic and clinicalscience aspects of the organs and diseases with whichthey should be familiar. A syllabus for this appearsbelow.

* Must have an adequate operative experience in endocrinesurgery. The BAES do not believe it is necessary tostipulate exact numbers of cases that must appear in thetrainees log book expecting an appropriate practical experience to flow from attachment to approved endocrine surgical trainers/units as defined above. It ishowever expected that the number of index casesspecified below (page 28) would be achieved.

* Should have an appreciation of relevant current researchbased on attendance at least one national or internationalendocrine surgical meeting per year.

BASIC SCIENCE CURRICULUM

GENERALAn understanding of:* The development of the endocrine glands and a detailed

knowledge of their anatomy including commonvariations in position.

* Endocrine physiology as outlined below.* The essentials of current techniques of

radioimmunoassay of hormones and of radiographic andisotopic techniques for localising abnormal endocrinetissue.

* A basic knowledge of the genetics of inherited endocrinedisorders.

SPECIFIC GLANDS

ThyroidThe role of Iodine in the normal function of the thyroid

including pathways of iodine metabolism. The physiologyof TSH and Thyrotrophin Releasing Factor. The functionsof T3 and T4. Role of thyroglobulin in thyroid physiology.Thyroid hormone release. The principles underlying thefunctioning of the pituitary thyroid axis. Tests of thyroidfunction. Thyroid antibodies and their significance. Anunderstanding of the physiological impact of GravesDisease on normal bodily functions. Mechanisms ofophthalmic manifestations of Graves Disease.. Calcitoninand its significance within the body.

Parathyroid glandsAn understanding of the metabolism of calcium. The

structure of parathyroid hormone. The control of calciummetabolism. The activity of PTH on kidney, gut and bone.D Vitamins and their function. The measurement of PTH.

The pituitaryStructure. Cells of origin, the basic metabolism and

function of anterior pituitary hormones without feedbackloops (growth hormone and prolactin) and those withfeedback loops (FSH, LH, TSH and ACTH).Hypothalamic pituitary pathways and related releasingsubstances. Corticotrophin releasing factor and itsrelationship to ACTH. Physiology of ACTH includingdiurnal variation. ACTH changes in response to stress,illness and trauma.

Adrenal cortexThe biosynthesis of glucocorticoids. Physiology of

glucocorticoids. Metabolism of cortisol and a knowledgeof those metabolites which are measured in clinicalpractice. The physiology of adrenal androgens and theeffects of pathological overproduction. The mineral-ocortcoids. The physiology of aldosterone. Anunderstanding of the renin angiotensin mechanisms. Aknowledge of tests of adrenal cortical function.


Adrenal MedullaMetabolic pathways of Adrenaline and Noradrenaline

production. The assessment of adrenal medullar activity.An understanding of the pathophysiology of excesscatecholamines.

The gut as an endocrine organAn appreciation of the physiology of gastrin, insulin,

glucagon, pancreatic polypeptide, VIP, secretin andsomatostatin.

CLINICAL CURRICULUM

An understanding of the principles of endocrineinvestigation, biochemical, radiological, isotopic,cytological and histological. Including strategies forminimising intervention and cost. Limitations ofinvestigation. An understanding of the concepts ofsensitivity, specificity etc.

FOR SPECIFIC CONDITIONS:Knowledge of pathophysiology and pathology.Outline of medical investigations.Details of imaging.Methods of biopsy.Interpretation of histological and cytologicalspecimensTreatment options. Surgical vs. other.Preoperative preparationAnaesthetic and pharmacological peculiarities.Operative techniques and strategies.Postoperative care including substitutiontherapies.Additional and adjuvant treatment.Prognosis and strategies for follow up.Counselling and screening in familial diseases.

SPECIFIC TOPICS

Pituitary.Cushing’s including different options for managing microadenoma

Thyroid. Thyrotoxicosis including:AetiologyMedical and radioisotope therapyManagement of eye diseaseSurgical strategiesOrganisation of follow upMonitoring of replacement therapyThyrotoxicosis in PregnancyThyrotoxicosis in Childhood

Solitary noduleMultinodular GoitreRetrosternal goitreThyroid malignancy of ALL typesMedullary carcinoma and MEN type 2Ectopic thyroidThyroiditis

Technique of thyroidectomyTechniques and use of block dissections of neck.Complications of thyroidectomy.Management of RLN palsy.Control of suppressive thyroxine therapy.Role of Radiation therapy in thyroid malignancy.

ParathyroidPrimary, secondary and tertiary HPT.Investigation of hypercalcaemia.Management of acute hypercalcaemia.Strategies in parathyroidectomy.Technique of parathyroidectomy.Management of HPT in renal patients.Management of familial HPT.Management of HPT in MEN patients.Management of recurrent and persistent HPT.Parathyroid autotransplantation.Parathyroid carcinoma.Management of hypocalcaemia.

Other Neck PathologyFamiliarity with parotid and submandibularsalivary gland disease, Thyroglossal cysts, Branchial Cysts and the causes and managementof cervical lymphadenopathy.

AdrenalCushing’s Disease and Syndrome:Investigation.Indications for adrenalectomy.Nelson’s syndrome.Conn’s syndrome.Incidentalomas.Phaeochromocytoma.Pharmocological and anaesthetic management ofphaeochromocytoma.MEN type 2Other adrenal endocrine tumoursAdrenal malignancyStrategies and routes for adrenalectomyReplacement therapy

Pancreas and gut.InsulinomasGastrinomas and ZE SyndromeMEN 1Carcinoid syndromeOther endocrine tumours of gut.


INDEX CASES

Performed Assisted

Thyroid Lobectomy 20 30

Parathyroid 10 20

TO BE A GENERAL SURGEON WITH ANINTEREST IN ENDOCRINE SURGERY

The trainee must be competent to perform:

Thyroid Lobectomy/isthmectomy.

Sub-total thyroidectomy (including Graves Disease).

Total Thyroidectomy.

Thyroglossal cyst excision.

TO BE A SUB-SPECIALIST IN ENDOCRINE SURGERY

The trainee would normally be expected to be competent toperform:

Thyroid Lobectomy/isthmectomy.

Sub-total thyroidectomy (including Graves Disease)

Total Thyroidectomy.

Thyroglossal cyst excision.

Thyroidectomy for advanced malignancy.

Re-operative thyroid surgery.

Modified block dissection of neck for thyroidmalignancy.

Parathyroidectomy.

Adrenalectomy.

Surgery for tumours of the endocrine pancreas.

Surgery for gastrointestinal endocrine disease.

This operative experience will be assessed fromthe SAC approved Log Book.

GUIDELINES FOR THE SURGICAL MANAGEMENT … · Cushings Syndrome 12 Primary Hyperaldosteronism -...

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