I'm a general surgeon in Modesto, California, USA. I started my own practice called Surgical Artistry with my wife Dr. Tammy Wu who is a plastic surgeon. We specialize in Acupuncture, BOTOX, Dermal Fillers such as Juvederm, Vein procedures, Face Vein Laser, Breast Augmentation, Tummy Tuck, Face Lift, Liposuction, Mole Removal and other aspects of plastic surgery.
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The disease of hyperparathyroidism is diverse. The causes of it are very different. As a simplification there’s primary, secondary and tertiary hyperparathyroidism:
All three of these involves increased PTH (parathyroid hormone)
Primary: elevated calcium, low phosphorus in blood stream. Usually caused by a parathyroid adenoma.
Secondary: normal or low calcium, usually caused by renal failure.
Tertiary: failure of treatment of secondary hyperparathyroidism to correct increased PTH.
More details on hyperparathyroidism
Primary hyperparathyroidism is most commonly caused by adenomas, greater than 85%. Next most common cause would be hyperplasia which is 10% of the causes, and there is a 1% possibility that primary hyperparathyroidism is caused by a carcinoma.
Risk factor for primary hyperparathyroidism includes family history, MEN I and MEN IIa, and also radiation. Major difference between MEN IIA and IIB: MEN IIA has Hyperparathyroidism – hyperplasia, MEN IIB does not. More on MEN syndromes.
To help remember these numbers I’ve simplified the ranges. Please look up these actual values in other sources, these numbers are just easier to remember without a written reference. These are just crude numbers within the normal range. The units have also been left off. So this really is not a reliable source of info.
Disclaimer: These are notes only. Every patient and condition is different and requires a in person consultation with a medical doctor. No medical advice is contained here, just academic discussion which may be very different from real life. There’s always ongoing trials and the information here may be out of date.
Postoperative Iodine 131 to diagnose / treat metastasis if a total thyroidectomy was done.
F’s of Follicular Cancer of the Thyroid
Far away metastasis (spreads hematogenously)
FNA NOT (FNA cannot be done to diagnosis Follicular Cancer of the thyroid
Female predominance (3:1)
M’s of Medullary Cancer of the Thyroid
MEN II (Multiple Endocrine Neoplasia type II)
Median Lymph Node dissection
Modified neck dissection if lateral nodes are positive
Stimulated by Pentagastrin
Cancer of the Thyroid C cells = parafollicular cells
Calcitonin (tumor marker for MTC)
Reduces blood levels of Calcium
Opposed the effects of PTH (parathyroid hormone)
Calcitonin is used as a tumor marker for medullary thyroid cancer (MTC)
Pentagastrin has effects like gastrin
Pentagastrin is used as a stimulation test to elevate serotonin levels and cause symptoms of carcinoid syndrome, provoking flushing.
Pentagastrin has been used to stimulate ectopic gastric mucosa for the detection of Meckels diverticulum by nuclear medicine.
Pentagastrin-stimulated calcitonin test is a diagnostic test for MTC (Medullary carcinoma of the thyroid). In patients with suspected MTC but borderline levels of calcitonin, injecting pentagastrin will cause calcitonin levels to rise tremendously.
When thinking of neck zones, there are those zones used in trauma and there are those used for cancer surgery.
The neck zones or levels depicted here are for cancer surgery. Lymph nodes or neck masses in these areas are described using these locations:
Picture copied from internet
In patients presenting with solid neck masses – those masses associated with the thyroid move with swallowing. Those in levels 3,4, and 5 do not move with swallowing.
Metastatic lymph nodes found in level 6 – could come from thyroid.
U/S and FNA should be performed after exam/history for Solid Neck Mass.
With well differentiated thyroid cancers, there is a high rate of cervical metastasis particularly with papillary cancers.
With lateral lymph nodes involved in thyroid cancer, survival rate is not improved significantly with LN dissection in the neck for patients older than 60 years old or for men with a 4 cm or larger well differentiated cancer.
Prophylactic lymph node dissections does not seem to improve survival with patients undergoing thyroid cancer treatment.
If thyroid tumor is small with documented (U/S) lateral lymph nodes. There is a benefit to dissecting level 3 or 4 lymph nodes (lymph node dissection or modified dissection) in the younger patient.
When a patient has a DNR order and needs a surgery with anesthesia, consider discussing the revoking the DNR order temporarily or focusing on what the patient wants for quality of life.
Unrelated urgent surgery to terminal illness + DNR order = some hospitals rescind the DNR order x 24 hours with careful documentation of the time.
High quality X-ray and multiple views of the X-ray may be required when looking for a possible retained sponge from surgery.
Some surgeons believe that the patient should be informed when the sponge / instrument counts are inaccurate at the end of a case even if there is no retained objects found on X-ray.
Laws vary regarding protection from apologizing.
Negligence = failure to exercise standard of care (reasonably prudent person / same situation).
First element of informed consent, decide whether the person is competent of making decisions on behave of themselves, their child or their family member.
To honor a patient’s request to make a medical/surgical decision for them, you must have already established a relationship with the patient, no other good options, believe that the course of the option is best for the patient.
Parents disagreeing, first determine if only one parent or both parents have the legal right to give permission.
A durable power of attorney is a type of advanced directive which may include other legal issues such as financial issues.
The advanced directive of a patient trumps the wishes or demands of a family member or surrogate.
A surgeon’s fine motor skills doesn’t appear to decline with age.
Just recently a trauma nurse at Memorial Hospital, Modesto, CA was discussing with me the trouble with some of the newer anticoagulants. She was saying that the bleeding was hard to reverse when the patients are on some of the newer anticoagulants. I was trying to figure out which ones she was talking about and she said that if I had named them, then she would know. So here’s my possible list of what was on her mind:
If it wasn’t Fondaparinux (above), then you’re probably thinking of Dabigatran/PRADAXA, Rivaroxaban/XARELTO or Apixaban/ELIQUIS. Can’t just push FFP, vitamin K or Factor VII for anticoagulation reversal. Any one of these on your mind?
Melanoma in-situ. 5mm resection margin is needed. (only 5 mm). In Situ = outer layer of the skin only (epidermis only)
Currently Melanoma SLN positive mandates lymphadenectomy in melanoma.
Patients with Familial Adenomatous Polyposis and Desmoids, ~10% of the tumors will have a very rapid and aggressive course. In FAP, there is a nearly 100 percent risk of colorectal cancer in the absence of treatment for polyposis.
Uncontrolled local recurrence is the main cause of death with retroperitoneal sarcomas.
Radiation therapy generally has not been shown to help low grade completely resected extremity sarcomas.
Flat colorectal polyps: ~25% contain high grade dysplasia.
SLN in colorectal cancer increases the accuracy of lymph node cancer status but often does not change the operation.
Stage III colorectal cancer, all chemotherapy regimens seem to improve outcome. Another related topic: Stage 4 colon cancer.
T2 colorectal lesions have a local recurrence rate of about 22%. With resection you induce a 20% local recurrence rate on a T2 cancer which had a 80% cure rate before resection. Salvage operations for local recurrence are associated with a 40-60% cure rate. Therefore, there is a 20% chance that a T2 patient survival will be reduced by doing a local resection (ie. transanal).
Rectal cancers. Size of an adenocarcinoma after initial preoperative chemotherapy is more predictive than the initial size of the tumor.
More advanced Gallbladder tumors, stage II, should be treated with a completion radical cholecystectomy – partial hepatectomies of the gallbladder bed with hepatoduodenal lymphadenectomy. Stage II: This means that cancer has grown through the muscle layer of the gallbladder wall and into the connective tissue underneath. It has not spread outside the gallbladder. Stage 2 in the TNM stages is the same as T2, N0, M0.
Metastasis found in remote lymph nodes in gallbladder cancer portend a poor prognocis.
PET scans doesn’t help distinguish acute or chronic cholecystitis vs. gallbladder cancer.
Endoscopic ultrasound should be used often in evaluating patients with pancreatic cysts.
If a pancreatic cyst wall has any nodularity then it may be malignant or on it’s way.
Pancreatic cancer, the risk of malignancy is lower for side branch intraductal papillary mucinous neoplasm than for main duct IPMNS.
Statistically, patients with pancreatic intraductal papillary mucinous neoplasms have an increased risk of colon and breast cancer.
Jaundice is not an emergency. First understand the root cause before reflexively draining the bile duct.
Parenchymal metastasis from a primary tumor such as lung metasis or liver metastasis, etc – those pts tend to do very poorly with peritoneal chemotherapy.
GIST (Gastro Intestinal Stromal Tumors) – standard therapy is gleevec (IMATINIB). Metastatic disease may have resistance to the drug
For patients with Colon cancer primary with metastasis to the liver with < or = 6 tumors in the liver where R0 resection (resection for cure) can be done, then these patients are reasonable candidates for resection surgery.