Aims Patients undergoing thyroidectomy for Graves’ disease are at increased risk of post-operativ... more Aims Patients undergoing thyroidectomy for Graves’ disease are at increased risk of post-operative complications and therefore require additional pre-operative preparation and close post-operative assessment. This study aimed to assess the pre- and post-operative management and morbidity in a single UK tertiary centre. Method Retrospective analysis of patients undergoing thyroidectomy for Graves’ between 2014–19. The primary endpoint was thyroid status pre-operatively and post-operative morbidity. Secondary endpoints were administration of potassium iodide, vitamin D and beta blockers and assessment of post-operative parathyroid function. Results Ninety-two thyroidectomies were undertaken for Graves’ in the five-year period. Pre-operatively 98% were successfully rendered euthyroid or hypothyroid and 2% hyperthyroid but required emergency surgery. Post-operative hypocalcaemia occurred in 26% but was temporary in 92%. Vocal cord palsy was found in 11%, but in all cases was temporary (...
The Annals of The Royal College of Surgeons of England, 2019
Introduction Near-infrared imaging may facilitate intraoperative identification of parathyroid gl... more Introduction Near-infrared imaging may facilitate intraoperative identification of parathyroid glands by causing autofluorescence but its clinical value has not been established. Inadvertent parathyroidectomy occurs in 5–22% of thyroidectomies and is associated with temporary and permanent hypoparathyroidism. The aim of this study was to determine whether near-infrared imaging prevents inadvertent parathyroidectomy and early hypocalcaemia as a surrogate for permanent hypoparathyroidism. Materials and methods Near-infrared imaging was used in a prospective cohort of consecutive thyroidectomies. Thyroidectomies performed prior to the introduction of near-infrared imaging formed a control group. The thyroid bed and specimen were scanned with near-infrared imaging. Areas of autofluorescence on the specimen were examined and any parathyroid tissue found was autotransplanted. Inadvertent parathyroidectomy was therefore recorded as established intraoperatively by near-infrared imaging (all...
International journal of surgery (London, England), Jan 22, 2016
Transaxillary robotic surgery (TARS) was pioneered in South Korea where cultural factors, anthrop... more Transaxillary robotic surgery (TARS) was pioneered in South Korea where cultural factors, anthropometry and remuneration favour this approach. Moreover, small thyroid nodules account for the majority of cases due to a national thyroid cancer screening programme. The technique has not been evaluated in the United Kingdom where larger thyroid nodules tend to undergo surgery in a patient population with a significantly higher body mass index (BMI). Prospective, non-randomised study. Sixteen consecutive TARS patients compared to 16 open thyroidectomy controls. There was no need for open conversion and no significant difference regarding pain, voice, or quality of life (QoL). In the TARS group there was one recurrent laryngeal nerve (RLN) paresis and one shoulder dysfunction. Both resolved within 4 weeks. Scar cosmesis was superior following TARS even after 3 years (p=0.02) but operative time significantly longer (228min vs. 85min, p=0.01). This study highlights the considerable differen...
European Journal of Surgical Oncology (EJSO), 2015
S S85 Comparisons with historical cohorts from this region shows a significant increase in the pr... more S S85 Comparisons with historical cohorts from this region shows a significant increase in the proportion of DTC (65% in the 1960s, 58% in the 1980s and 87% currently. Conclusion: The incidence of thyroid cancer in South Yorkshire is lower than many other parts of Europe. Age and gender distribution of each type is similar to published series and the causes of increased incidence are explored. http://dx.doi.org/10.1016/j.ejso.2015.08.094 19. Parathyroidectomy in Pregnancy: A single centre 10-year experience Paul C. Dent, Niyati Lobo, Susan Kirby, Neil S. Tolley, F.Fausto Palazzo Hammersmith Hospital, Imperial College Healthcare NHS Trust, UK Introduction: Primary hyperparathyroidism (PHPT) affects approximately up to 0.15% of the population with an almost 3:1 female to male ratio. However the prevalence of PHPT in women under the age of 40 is thought to be less than 4/10,000. It is suggested that PHPT in pregnancy in addition to the standard morbidity is associated with a risk of miscarriage and fetal death but best practice is not evidence based. We present our 10 year experience of parathyroidectomy performed during pregnancy. Methods: We retrospectively reviewed a prospectively maintained audit database of all cases of parathyroidectomy performed between 2005 and 2015 and identified operations performed in pregnant women. Data analysed include patient demographics, clinical features, preand post-operative biochemical studies, radiological and pathological findings, and outcome of pregnancy. Results: 932 parathyroidectomies were performed for PHPT between 2005e2015 and 12 women (aged 34.9 4.1 years) were pregnant at the time of surgery. The mean corrected calcium was 2.96 0.19 mmol/L with a PTH 16.7 10.6 pmol/L. Ultrasound localization was performed in all patients prior to surgery and 4/13 were helpful in localizing the correct parathyroid gland. Parathyroidectomy was performed with an obstetric anaesthetist. 12 patients were in the second trimester and 1 in the early third trimester (19.7 3.6 weeks). Anaesthetic time was 61.3 16.7minutes. Cure was achieved in 11 patients at first surgical intervention with no reported complications at follow up. The one patient with mild persistence/recurrence (normal corrected calcium and PTH level immediately post-operatively with an unaccommodated PTH at 6 months), had undergone a minimally invasive parathyroidectomy under LA. All foetus’ had a normal pre& post operative heart monitor. There were no immediate maternal or foetal complications and all completed their pregnancy. Conclusion: Parathyroidectomy during pregnancy is safe with obstetric anaesthesia. The absence of nuclear imaging makes four gland visualisation the approach most likely to achieve permanent cure. http://dx.doi.org/10.1016/j.ejso.2015.08.095 20.Anatomic study of the external branch of the superior laryngeal nerve. Anatomic findings and its implication in thyroid surgery Xenophon Kochilas, Konstantinos Argiris, Thanos Bibas 1 Brighton and Sussex Universities NHS Trust, UK Hippocration University Hospital Athens Greece, Honorary Reader in Otolaryngology, Ear Instituted UCL, London, UK Introduction: The External Branch of the Superior Laryngeal Nerve (EBSLN) has been described as the “neglected” in thyroid surgery. The purpose of this study was to describe the topography of the EBSL and its relationship to the adjacent anatomical structures. Material and Methods: 21 formalin-embalmed human cadavers of both sexes ranging in age from 52 to 94 (mean, 78 years) were included in this study. A total of 42 superior thyroid poles (SPT) were dissected and the exact course of the EBSLN was identified and its relationship to: i) the superior pole of the thyroid gland (SPTG) ii), the superior thyroid vessels (STV), and iii) the inferior constrictor muscle of pharynx (ICMPH) was noted. Results: The EBSLN was identified in 41 specimens (97.61%). In (19.04%) the EBSLN was crossing the STV > 1 cm above the SPTG In (54.76%) the EBSLN was crossing the STV A at 9q22.23 in a Western European cohort of patients with thyroid cancer compared to controls. Methods: DNAwas extracted from buccal swabs or whole blood of patients with differentiated non-medullary thyroid cancer by ethanol precipitation. Patients were recruited from two tertiary referral centres in Ireland and France. Cancer-free controls were recruited from the community. Genotyping was performed using Taqman-based PCR. Data was analysed using SPSS V22. Results: One hundred and eighty one cases and eighty-three controls were genotyped for the variant. The frequency of the minor allele among cases was 0.46 compared to 0.31 among controls. The genotypic odds ratio for heterozygous carriers was 2.41 (1.36e4.26, p 1⁄4 0.002), increasing to 3.56 (1.48e8.53, p 1⁄4 0.003) for rare homozygotes. Conclusion: The FOXE1 variant was identified in patients with thyroid cancer significantly more frequently than controls in both heterozygous and homozygous forms. An allele…
A best evidence topic was written according to a structured protocol. The question addressed was ... more A best evidence topic was written according to a structured protocol. The question addressed was whether there is a role for intraoperative recurrent laryngeal nerve monitoring during high mediastinal lymph node dissection in three-stage oesophagectomy for oesophageal cancer. A total of 125 papers were identified using the reported searches of which 2 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, study type, patient group, relevant outcomes and results are tabulated. Oesophageal surgery, similar to thyroid, parathyroid and cardiothoracic surgery poses a risk to the recurrent laryngeal nerves (RLN). Intraoperative RLN monitoring (IONM) is commonly being used in thyroid and parathyroid surgery in many centres. The same does not hold true for three-stage oesophagectomy with high mediastinal lymph node dissection despite the inherent risks to the RLN being much higher with this type of surgery. There are only a handful of studies in the literature evaluating the role of IONM in three-stage oesophagectomy. As a result, there is limited evidence to provide robust guidance. The evidence from the present review supports the use of IONM during high mediastinal lymph node dissection in three-stage oesophagectomy for oesophageal cancer. IONM appears to have a protective role for the RLN and also reduce the risk of postoperative pneumonia without adding to the operative time. In patients due to undergo three-stage oesophagectomy, the use of IONM of the RLN should be considered during the high mediastinal lymph node dissection and cervical access parts of the operation.
We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The pat... more We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy.
Aims Patients undergoing thyroidectomy for Graves’ disease are at increased risk of post-operativ... more Aims Patients undergoing thyroidectomy for Graves’ disease are at increased risk of post-operative complications and therefore require additional pre-operative preparation and close post-operative assessment. This study aimed to assess the pre- and post-operative management and morbidity in a single UK tertiary centre. Method Retrospective analysis of patients undergoing thyroidectomy for Graves’ between 2014–19. The primary endpoint was thyroid status pre-operatively and post-operative morbidity. Secondary endpoints were administration of potassium iodide, vitamin D and beta blockers and assessment of post-operative parathyroid function. Results Ninety-two thyroidectomies were undertaken for Graves’ in the five-year period. Pre-operatively 98% were successfully rendered euthyroid or hypothyroid and 2% hyperthyroid but required emergency surgery. Post-operative hypocalcaemia occurred in 26% but was temporary in 92%. Vocal cord palsy was found in 11%, but in all cases was temporary (...
The Annals of The Royal College of Surgeons of England, 2019
Introduction Near-infrared imaging may facilitate intraoperative identification of parathyroid gl... more Introduction Near-infrared imaging may facilitate intraoperative identification of parathyroid glands by causing autofluorescence but its clinical value has not been established. Inadvertent parathyroidectomy occurs in 5–22% of thyroidectomies and is associated with temporary and permanent hypoparathyroidism. The aim of this study was to determine whether near-infrared imaging prevents inadvertent parathyroidectomy and early hypocalcaemia as a surrogate for permanent hypoparathyroidism. Materials and methods Near-infrared imaging was used in a prospective cohort of consecutive thyroidectomies. Thyroidectomies performed prior to the introduction of near-infrared imaging formed a control group. The thyroid bed and specimen were scanned with near-infrared imaging. Areas of autofluorescence on the specimen were examined and any parathyroid tissue found was autotransplanted. Inadvertent parathyroidectomy was therefore recorded as established intraoperatively by near-infrared imaging (all...
International journal of surgery (London, England), Jan 22, 2016
Transaxillary robotic surgery (TARS) was pioneered in South Korea where cultural factors, anthrop... more Transaxillary robotic surgery (TARS) was pioneered in South Korea where cultural factors, anthropometry and remuneration favour this approach. Moreover, small thyroid nodules account for the majority of cases due to a national thyroid cancer screening programme. The technique has not been evaluated in the United Kingdom where larger thyroid nodules tend to undergo surgery in a patient population with a significantly higher body mass index (BMI). Prospective, non-randomised study. Sixteen consecutive TARS patients compared to 16 open thyroidectomy controls. There was no need for open conversion and no significant difference regarding pain, voice, or quality of life (QoL). In the TARS group there was one recurrent laryngeal nerve (RLN) paresis and one shoulder dysfunction. Both resolved within 4 weeks. Scar cosmesis was superior following TARS even after 3 years (p=0.02) but operative time significantly longer (228min vs. 85min, p=0.01). This study highlights the considerable differen...
European Journal of Surgical Oncology (EJSO), 2015
S S85 Comparisons with historical cohorts from this region shows a significant increase in the pr... more S S85 Comparisons with historical cohorts from this region shows a significant increase in the proportion of DTC (65% in the 1960s, 58% in the 1980s and 87% currently. Conclusion: The incidence of thyroid cancer in South Yorkshire is lower than many other parts of Europe. Age and gender distribution of each type is similar to published series and the causes of increased incidence are explored. http://dx.doi.org/10.1016/j.ejso.2015.08.094 19. Parathyroidectomy in Pregnancy: A single centre 10-year experience Paul C. Dent, Niyati Lobo, Susan Kirby, Neil S. Tolley, F.Fausto Palazzo Hammersmith Hospital, Imperial College Healthcare NHS Trust, UK Introduction: Primary hyperparathyroidism (PHPT) affects approximately up to 0.15% of the population with an almost 3:1 female to male ratio. However the prevalence of PHPT in women under the age of 40 is thought to be less than 4/10,000. It is suggested that PHPT in pregnancy in addition to the standard morbidity is associated with a risk of miscarriage and fetal death but best practice is not evidence based. We present our 10 year experience of parathyroidectomy performed during pregnancy. Methods: We retrospectively reviewed a prospectively maintained audit database of all cases of parathyroidectomy performed between 2005 and 2015 and identified operations performed in pregnant women. Data analysed include patient demographics, clinical features, preand post-operative biochemical studies, radiological and pathological findings, and outcome of pregnancy. Results: 932 parathyroidectomies were performed for PHPT between 2005e2015 and 12 women (aged 34.9 4.1 years) were pregnant at the time of surgery. The mean corrected calcium was 2.96 0.19 mmol/L with a PTH 16.7 10.6 pmol/L. Ultrasound localization was performed in all patients prior to surgery and 4/13 were helpful in localizing the correct parathyroid gland. Parathyroidectomy was performed with an obstetric anaesthetist. 12 patients were in the second trimester and 1 in the early third trimester (19.7 3.6 weeks). Anaesthetic time was 61.3 16.7minutes. Cure was achieved in 11 patients at first surgical intervention with no reported complications at follow up. The one patient with mild persistence/recurrence (normal corrected calcium and PTH level immediately post-operatively with an unaccommodated PTH at 6 months), had undergone a minimally invasive parathyroidectomy under LA. All foetus’ had a normal pre& post operative heart monitor. There were no immediate maternal or foetal complications and all completed their pregnancy. Conclusion: Parathyroidectomy during pregnancy is safe with obstetric anaesthesia. The absence of nuclear imaging makes four gland visualisation the approach most likely to achieve permanent cure. http://dx.doi.org/10.1016/j.ejso.2015.08.095 20.Anatomic study of the external branch of the superior laryngeal nerve. Anatomic findings and its implication in thyroid surgery Xenophon Kochilas, Konstantinos Argiris, Thanos Bibas 1 Brighton and Sussex Universities NHS Trust, UK Hippocration University Hospital Athens Greece, Honorary Reader in Otolaryngology, Ear Instituted UCL, London, UK Introduction: The External Branch of the Superior Laryngeal Nerve (EBSLN) has been described as the “neglected” in thyroid surgery. The purpose of this study was to describe the topography of the EBSL and its relationship to the adjacent anatomical structures. Material and Methods: 21 formalin-embalmed human cadavers of both sexes ranging in age from 52 to 94 (mean, 78 years) were included in this study. A total of 42 superior thyroid poles (SPT) were dissected and the exact course of the EBSLN was identified and its relationship to: i) the superior pole of the thyroid gland (SPTG) ii), the superior thyroid vessels (STV), and iii) the inferior constrictor muscle of pharynx (ICMPH) was noted. Results: The EBSLN was identified in 41 specimens (97.61%). In (19.04%) the EBSLN was crossing the STV > 1 cm above the SPTG In (54.76%) the EBSLN was crossing the STV A at 9q22.23 in a Western European cohort of patients with thyroid cancer compared to controls. Methods: DNAwas extracted from buccal swabs or whole blood of patients with differentiated non-medullary thyroid cancer by ethanol precipitation. Patients were recruited from two tertiary referral centres in Ireland and France. Cancer-free controls were recruited from the community. Genotyping was performed using Taqman-based PCR. Data was analysed using SPSS V22. Results: One hundred and eighty one cases and eighty-three controls were genotyped for the variant. The frequency of the minor allele among cases was 0.46 compared to 0.31 among controls. The genotypic odds ratio for heterozygous carriers was 2.41 (1.36e4.26, p 1⁄4 0.002), increasing to 3.56 (1.48e8.53, p 1⁄4 0.003) for rare homozygotes. Conclusion: The FOXE1 variant was identified in patients with thyroid cancer significantly more frequently than controls in both heterozygous and homozygous forms. An allele…
A best evidence topic was written according to a structured protocol. The question addressed was ... more A best evidence topic was written according to a structured protocol. The question addressed was whether there is a role for intraoperative recurrent laryngeal nerve monitoring during high mediastinal lymph node dissection in three-stage oesophagectomy for oesophageal cancer. A total of 125 papers were identified using the reported searches of which 2 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, study type, patient group, relevant outcomes and results are tabulated. Oesophageal surgery, similar to thyroid, parathyroid and cardiothoracic surgery poses a risk to the recurrent laryngeal nerves (RLN). Intraoperative RLN monitoring (IONM) is commonly being used in thyroid and parathyroid surgery in many centres. The same does not hold true for three-stage oesophagectomy with high mediastinal lymph node dissection despite the inherent risks to the RLN being much higher with this type of surgery. There are only a handful of studies in the literature evaluating the role of IONM in three-stage oesophagectomy. As a result, there is limited evidence to provide robust guidance. The evidence from the present review supports the use of IONM during high mediastinal lymph node dissection in three-stage oesophagectomy for oesophageal cancer. IONM appears to have a protective role for the RLN and also reduce the risk of postoperative pneumonia without adding to the operative time. In patients due to undergo three-stage oesophagectomy, the use of IONM of the RLN should be considered during the high mediastinal lymph node dissection and cervical access parts of the operation.
We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The pat... more We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy.
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