42 • Specialist clinics


Healthcare Innovations • Sunday 26 July 2020


In contrast to other surgical sub-specialities, endocrine surgery is practiced by a small number of surgeons. Te British Association of Endocrine and Tyroid Surgeons has only 400 members, compared with over 2,000 members of its orthopaedic equivalent


Endocrine surgery


Endocrine surgery is a subspeciality hidden behind a label that bears little meaning to most people.


A direct translation would be ‘surgery for the hormones’ — this might help patients understand when they could benefit from the expertise of surgeons who share this branch of surgery. Hormones are chemicals released in the blood stream by several endo- crine glands that impact the func- tioning of distant tissues and organs. When


tumours develop in these


endocrine glands, an excess produc- tion of hormones takes place, thus amplifying the normal effect(s) of a particular hormone and triggering the symptoms reported by the patients. For example, above each kidney there’s an adrenal gland and one of its hormones is related to adrenalin. Terefore, a tumour of


the adrenal


gland producing too much adrenalin will lead to high blood pressure, fast/ irregular heartbeats, sweating and an overall feeling of doom and gloom.


My journey After graduating in 1991 from Carol Davila Faculty of Medicine, Bucha- rest, Romania, the University of Bristol


Patients’ journey Going back to the initial question of this article: who needs to see an endo- crine surgeon? A large part of our work deals with


became my second alma


matter. Te years spent in its labora- tories honed my scientific acumen, leading to a large number of publica- tions and the nomination as Hunte- rian Professor of Surgery by the Royal College of Surgeons. My general


conditions related to the thyroid gland. Such conditions include its excessive function (Graves disease), the development of a nodule within the thyroid, or an overall enlargement in the size of the thyroid (goitre) that can eventually press upon the wind- pipe and create breathing difficul- ties. Tyroid cancer is increasingly diagnosed in people at an earlier age, and so they will require immediate decisions about the extent of their surgical treatment and follow-up over several decades. An area of our practice that’s


RADU MIHAI


likely to expand relates to patients with tumours within their parathy- roid glands. Such tumours lead to an increase in the calcium levels in the blood, a condition called primary hyperparathyroidism. Although such biochemical abnormalities might be interpreted by other doctors as ‘mild’ or ‘minor’, patients may nevertheless be affected by a plethora of symp- toms that negatively impact their quality of life. Such symptoms may include severe tiredness, sleepiness, low mood, widespread aches and pain and possible development of kidney stones and worsening osteoporosis.


surgical training in the South West of England under the supervision of Professor John Farndon was followed by two more years as a Fellow before appointment on a definitive position as a Consultant in 2007, in Oxford. Working in a prestigious unit, but in a town with a small population, I knew that the service provided would have to be of such a quality as to encourage referrals from a wider geographical area. We owe the patients who present the most severe conditions the guarantee that a decision about their safe and effective operation will be based on a documented track record for favourable outcomes in similar patients.


Many patients experience extreme frustration at how slow and difficult the process of receiving a diagnosis can be, and how long they may have to wait before being referred for surgical treatment. Tere’s a clear need to facilitate and improve their access to surgical units that can provide the types of scans and surgical expertise necessary for a successful operation. Tis can only be achieved through increased awareness in primary care and through close collaboration with medical endocrinologists. Adrenal surgery deals with tumours


of the adrenal gland. Some of these tumours affect the body through excess secretion of cortisol that leads to severe weight gain, muscle loss, bruising, mood changes, hyper- tension and an increased risk of developing diabetes. Other tumours produce a hormone called aldosterone that increases the blood pressure, a condition called Conn’s Allegedly one


syndrome. in 20 hypertensives


have this condition, the risk being higher in patients diagnosed with hypertension at


young age, those


who don’t respond well to medication and need three to four drugs to control their blood pressure, and those associated with obstructive sleep apnoea. Te benefits of identi- fying such patients are significant, as removal of their adrenal tumour through a key-hole operation is


likely to improve (or cure) the raised blood pressure. I have a particular interest in


surgery for adrenocortical cancer, a very rare but very aggressive type of cancer affecting one in a million people. Most of these patients present with a very large tumour that needs a radical operation likely to include resection of the tumour en-block with surrounding organs, such as the kidney and spleen. I worked with several European colleagues while writing the guidelines for the treat- ment of adrenocortical cancer. In so doing, it became apparent that their vast personal experience is based on a system whereby patients travel long distances to recognised centres of expertise. This is a model in stark contrast to the ethos of NHS provi- sion, which is based on accessing services as close to home as possible. Adrenal surgery is currently in


need of significant reorganisation. On behalf of the European Society of Endocrine Surgeons, I led a working group to set out guidelines for such operations. The main recommen- dations were that adrenal surgery should be referred to centres that perform at least six cases per year, and that the most challenging cases should be referred to centres doing at least 12 cases per year. To put this in context, some 90-100 patients are operated every year in Oxford, repre- senting close to 10% of the workload for the entire UK.


The current professional context In contrast to other surgical sub-spe- cialities, endocrine surgery is prac- ticed by a small number of surgeons. Te British Association of Endo- crine and Tyroid Surgeons has only 400 members, compared with over 2,000 members of its orthopaedic equivalent. Te number of opera- tions performed every year in the UK include some 10,000 thyroid opera- tion, 6,000 parathyroid operations and 800 adrenal operations. Due to being relatively uncommon, many of these operations are performed


by surgeons with minimal experi- ence. For example, adrenal surgery is still performed by a large number of surgeons whose average annual workload is only one case per year, a situation that would be impossible to imagine for other sub-speciali- ties. A government-led nationwide review of practice is under way under the acronym GIRFT (get it right first time), aiming to find a mechanism to centralise adrenal surgery in a small number of specialised units.


Final comments Each patient facing a severe illness hopes to be seen by an expert in their particular problem who’ll deliver timely and up-to-date care. Tere’s little discussion about how such experts are trained and recognised by their peers. For endocrine surgery, only patients can help the transforma- tion of a surgeon into an expert in this field. Te positive impact of patients who are prepared to travel towards a centre with an established multidisci- plinary environment can’t be underes- timated. Input from patients’ support groups and guidance from medical endocrinologists should facilitate the process of finding a surgeon who submits his results to public scru- tiny, and whose practice has reached a critical volume through centralised referrals.


T: 07966 937 851


E: radumihai@doctors.org.uk radumihai.info


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