SUMMER 2011 Image by Wellcome Images
The newsletter for GPs from The Wellington Hospital
SPECIALIST FACILITIES AT THE PLATINUM MEDICAL CENTRE The latest news, views and features from the largest independent hospital in the United Kingdom
WELCOME As the rest of the community is winding down and looking forward to the summer holidays and warmer weather, The Wellington Hospital continues to be a hub of activity. The last few months have been essential in our development and progression as one of the world’s leading hospitals. In this issue you’ll find a feedback form asking for your thoughts on Practice Matters. Your feedback is hugely important to us, and we value communication with our local GPs very highly. Please take a moment to fill out the form and you’ll also be entered for the chance to win a family day out at London Zoo - perfect for the summer holidays. I hope you enjoyed the last edition of Practice Matters, which introduced you to the Platinum Medical Centre and the services we offer there. When the centre opened in May, our first stage was to open the outpatient areas, since then the cancer care unit, and the day case are now in action too. The new centre is very popular with both our patients and medical professionals, and yet this is only the beginning for us. As the Platinum Medical Centre continues to develop, do organise a tour with us and see first hand the facilities we are offering. The rest of the hospital is also making great impressions too. Congratulations to the Acute Neurological Rehabilitation Unit who were awarded with the prestigious CARF accreditation in May. You can read more about this award-winning unit on page 8.
New technology continues to play an integral part at the hospital. The latest addition to our state-of-the-art facilities is the new Endobronchial Ultrasound (EBUS), which is used for diagnosing and staging lung cancer, detecting infections, and identifying inflammatory diseases that affect the lungs, such as sarcoidosis or other cancers like lymphoma. In the next issue of Practice Matters we’ll take a closer look at EBUS and how it will benefit your patients. The Wellington Hospital blog is now live, which hosts a selection of consultant articles, news and updates; and you can now follow the hospital’s developments on Twitter and Facebook too. For more details turn to page 14. And lastly, at the end of this month we say farewell to our esteemed Postgraduate Dean, Dr Martin Sarner. Dr Sarner has been part of The Wellington Hospital for many years, first as a leading Gastroenterologist and more recently as The Wellington’s Post Graduate Dean. I’m sure many of you will be familiar with Dr Sarner, and will join me in wishing him all the best in his retirement. I wish you all a fantastic summer ahead,
Keith Hague, CEO
INSIDE THIS ISSUE MANAGING LIVER METASTASES
Mr Fusai discusses what can be done when bowel cancer has spread to the liver.
4 A BRIGHT FUTURE FoR SkIN CANCER CARE At the PMC the team provides integrated care for patients throughout the continuum of the disease process.
10 THyRoID AND PARATHyRoID DISEASE
EDITORIAL TEAM Claire Allen
Tel 020 7483 5109
Management & Distribution
Tel 020 7483 5336
A review of the history and management issues of these endocrine organs and options available today.
Comments, personal views & opinions expressed by contributors are not necessarily those of The Wellington Hospital.
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PLUS: oUR REGULAR CoLUMNS
practicematters summer 2011
WELLINGTON IN FOCUS
The heart of the matter
Part 1: Palpitations Cardiologists see patients with a variety of problems, and over the next three issues of Practice Matters I will describe a series of illustrative cases (details have been altered to protect patient confidentiality). Case 1 – Palpitations Mr S is a 77 year old retired business man. He went to his GP complaining of uncomfortable palpitations. He rarely saw his GP other than for occasional checks on his blood pressure, for which he was taking an ACE inhibitor, so the GP decided to refer him to my clinic. The GP sent off routine bloods including a full blood count, renal function and thyroid function. The results of all these were normal. Mr S told me that he would suddenly feel his heart racing. The attacks were becoming more frequent – now about 2 -3 times per week. The episodes would last for up to an hour and could occur at any time of day. Although he was quite uncomfortable during the episodes he did not experience any worrying symptoms such as syncope or near syncope. There was no history of thyroid problems in the family, he rarely drank alcohol; the examination was unremarkable. He was clinically euthyroid, there were no cardiac murmurs and his blood pressure was a little raised at 150/90. I ordered: • A 12 lead ECG – to see if there was any clues to a tendency to arrhythmia. The ECG was normal. (Figure 1) • A 48 hour ambulatory monitoring tape to try to capture the heart rhythm during symptoms (Figure 2) • An ECHO cardiogram to assess cardiac function and chamber size. This showed normal left ventricular function, no evidence of valvular heart disease but moderate left atrial dilatation. The 48 hour tape showed episodes of paroxysmal atrial fibrillation which coincided with Mr S’s symptoms.
Enquiry Helpline: 0207 483 5148
Dr Robert Greenbaum is a Senior Consultant Cardiologist at The Wellington Hospital. His NHS bases are Barnet and The Royal Free Hospitals. He is a Past President of the Cardiology Section of The Royal Society of Medicine.
“I manage patients with all aspects of heart disease and specialise in coronary angiography, coronary angioplasty and pacemaker implantation. I also care for patients with heart failure, palpitations or heart rhythm disturbances and blood pressure and cholesterol problems.”
Treatment This was aimed at two aspects of the problem of paroxysmal atrial fibrillation. 1. Reduction of the risk of stroke There are formulae available to calculate the risk of stroke without treatment in such patients. In Mr S’s case the risk was 3.2% per year: over ten years a 1 in 3 risk. Treatment with warfarin reduces the annual risk by almost three quarters – in this case to about 1%. It is likely that there will be major changes in this aspect of management over the next couple of years. Several pharmaceutical companies are in the advanced stages of developing new oral anticoagulants. These are likely to largely but not completely replace warfarin over the next few years. One such agent is dabigatran (Pradaxa®). This is currently only licensed in the UK for short term use preventing deep venous thrombosis during hip and knee replacement surgery. It has been licensed for stroke prevention in atrial fibrillation in the USA and is likely, in my view, to get similar authorisation in this country soon. Dabigatran has been shown in a large clinical trial to be at least as effective as warfarin in the prevention of stroke. The important advantage of dabigatran is that there is no need for blood tests to monitor treatment. For the moment I have treated Mr S with Warfarin aiming to maintain his INR between 2 – 3. He is keen to switch to dabigatran once it is licensed for this indication. 2. Treatment of the arrhythmia I chose to treat Mr S initially with bisoprolol a beta blocker. Although there are more effective treatments such as amioderone available they tend to have more frequent side effects. Although the bisoprolol did not prevent all the attacks they became much less frequent
Figure 1 – 12 EGC Lead
Figure 2 – 48 Hour Ambulatory Monitoring Tape To arrange a referral, please contact the Enquiry Helpline on 0207 483 5148 website: http://www.theheart.co.uk Follow me on Twitter: @RobertGreenbaum
– about one every couple of months and rather shorter in duration. Overall Mr S is feeling much better. He has accepted the need for warfarin but is waiting for dabigatran to be licensed.
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The London Skin Cancer Specialist Service at the Platinum Medical Centre is a fully integrated multidisciplinary programme, providing excellent comprehensive care throughout the disease continuum. The facility is designed to accommodate an increasing patient population and the clinical specialist faculty to service their needsâ€Ś
A bright future for Together, The London Skin Cancer Specialist team provide integrated care for patients throughout the continuum of the disease process: from diagnoses, through surgical management and chemo, or radiotherapy for advanced disease. outstanding Expertise Chaired by Mr Ciaran Healy, Consultant Plastic Surgeon, the skin cancer team at the PMC is lead by Prof Sean Whittaker in Dermatology, Dr Nick Francis in DermatoPathology, Dr Paul Nathan in Oncology, and co-ordinated by Charge Nurse Ali Bautista. Each participating consultant in the London Skin Cancer Specialist Service has held senior positions at NHS teaching hospitals and contributes to the ongoing development of the speciality. Networked Care; Prompt Diagnoses Patients, GPs and referring consultants have rapid access to a co-ordinated service, which provides prompt assessment of suspicious skin lesions by our dedicated team of highly experienced dermatologists and plastic surgeons. Where appropriate surgical excision under local anaesthetic - can be carried out during the initial consultation, in dedicated treatment areas contained within the unit. Our dermato-pathology team provide prompt analysis of the suspicious lesions, their comprehensive reports being available on the HCA intranet. This allows our clinicians to provide the patient with accurate information regarding their clinical status during their review appointment. 4
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If benign, this may involve reassurance only. If it transpires that the lesion is malignant, the excision biopsy may be sufficient treatment for basal and well differentiated squamous cell carcinoma. Again, the patient can be reassured but follow up is indicated to monitor recurrence, or new lesions developing. Patients also require education regarding sun exposure for themselves and their children. For incompletely excised basal and well differentiated squamous cell carcinoma, moderately and poorly differentiated carcinoma and most melanomas, more extensive surgical treatment is required. Prior to this, a comprehensive survey of the patient by our PET CT Scanner may be necessary, to rule out extensive metastatic disease.
Images courtesy of Richard Blower Photography
Multi-disciplinary Team Skin cancer is disfiguring, dangerous and increasing in incidence. The management of this complex range of cancers is optimised by multidisciplinary team care. At the Platinum Medical Centre (PMC) a dedicated unit brings together dermatologists, plastic surgeons, pathologists and oncologists with specific expertise in the evolving techniques of diagnoses and treatment of basal and squamous cell carcinoma, melanoma, dermatofibrosarcoma and cutaneous lymphoma etc.
skin cancer care The Wellington Hospital is a centre of excellence for this type of reconstructive surgery, with a dedicated team of operating theatre and ward staff supporting it. Advanced surgical assessment of tumour staging through Sentinel Lymph Node Biopsy is routinely performed by our plastic surgical team with experience of over 1,000 cases. This procedure is facilitated by pre-operative lymphoscintigraphy at The Wellington Nuclear Medicine department and intra-operative gamma probe localisation. Complex Skin Cancer Cases Recurrent skin cancer cases require specialist teams to achieve tumour eradication and reconstruction. Basal cell carcinoma recurrence in areas such as the nose can result in extensive destruction, and are difficult to eradicate. The London Skin Cancer Specialist Service provides micrographic tumour surgical eradication (Mohâ€™s); allowing for immediate plastic surgery reconstruction of the cancer free defect.
Specialist Surgical Care Our team of plastic surgeons have extensive expertise in the surgical management of biopsy proven skin cancers of all types, and work within the protocols established by national clinical organisations to which they are affiliated. Where the skin cancer excision defect is small, and located within an area of local skin laxity, direct wound closure may be appropriate. With larger defects, and those encroaching upon important structures, more complex reconstruction may involve skin grafting, local, distant and free flap reconstruction.
Enquiry Helpline: 0207 483 5148
Skin cancer recurrence may involve the regional lymph nodes requiring radical dissection of the axilla and groin. Our plastic surgical team provides comprehensive management of such cases, in addition to reconstructing associated defects. Where essential structures, such as major vessels, require removal to achieve tumour clearance, our plastic surgeons work with colleagues from other specialities such as vascular surgery, to provide comprehensive reconstruction of the most complex defects. Skin Cancer Specialist oncology The London Skin Cancer Specialist Service oncologists advise on appropriate staging investigations, possible further surgical care and adjuvant therapy. Melanoma advanced disease treatment is evolving rapidly, with molecular analysis guiding novel immunotherapy. IMAGES 1 Mr Richard Blower (professional photographer) presenting with
a malignant melanoma on his left cheek. 2 Six months follow up of left cheek post melanoma reconstruction.
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WELLINGTON IN FOCUS
METASTASES Mr Giuseppe Fusai is a General Surgeon specialising Liver and HPB surgery at The Royal Free and The Wellington Hospital
This article first appeared online, at www.totalhealth.co.uk http://www.totalhealth.co.uk/clinical-experts/mr-giuseppe-kito-fusai/livermetastases-what-can-be-done-when-bowel-cancer-has-spread-liver
Mr Giuseppe Fusai discusses what can be done when bowel cancer has spread to the liver and highlights the importance of a multidisciplinary management approachâ€Ś Bowel cancer can spread to various other organs, most commonly to the liver. Liver metastases occur in more than half of patients with bowel cancer and can often be treated surgically, or in combination with other treatment modalities. The Bowel and Liver Cancer Link In Europe, bowel cancer is the second most common malignant tumour in women and the third most common in men. Each year approximately 700,000 new cases are diagnosed and 400,000 people die from colorectal cancer worldwide. In the UK, about 34,000 new cases are diagnosed each year. Of these approximately 60% develop metastatic disease, of which, half will be localised to the liver alone. Liver metastases may occur either at the same time that bowel cancer is diagnosed - (synchronous metastases) or after the primary tumour has been resected (metachronous metastases). Surgery is the only potentially curative treatment for these patients, although in the past only 10-30% were considered suitable for resection. Without surgery, the average survival with palliative treatment is usually less than 2 years. At least 20 -30 % of the liver must be saved Several factors are important to determine whether a patient is deemed suitable for surgery. The distribution of the metastases 6
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dictates the technical feasibility, as at least 20-30% of the liver must be preserved to prevent liver failure. However, the liver has a unique peculiarity in that it is the only organ capable of regeneration if part of it is removed. Indeed, a second and third reoperation can be performed to remove recurrent metastases, with an outcome similar to the one observed in patients after the first surgical procedure. For this reason it is essential that patients are followed up for at least five years after surgery with repeat CT scans every three to four months for the first two years and six monthly or yearly thereafter. Fit for Liver Surgery It is essential that patients are generally fit to undergo major surgery, though many octuagerians are routinely and successfully operated on. Improvement in peri-operative care, including anaesthesia and intensive care support, as well as technical progress in surgical equipment, have led to a dramatic decrease of postoperative mortality. This improvement is also associated with better management of the complications, which occur in 20-40% of patients, the most serious ones being bleeding, infection, bile leakage and liver
The right portal vein is embolized to promote preoperative regeneration of the remnant liver
A large liver metastasis from colorectal cancer has been successfully downsized with preoperative chemotherapy
failure. A particularly important advance over the last few years has been the development of minimally invasive liver surgery, though this is only an option in selected cases. The benefit of this approach is mainly to expedite recovery and discharge. Patients can get out of bed the following day, have very little pain and go home a few days after surgery. Combining Treatments for Liver Cancer In recent years various strategies have increased the number of cases who can benefit from surgical treatment. Chemotherapy plays a key role and virtually all patients with liver metastases from colorectal cancer receive it at some stage. Chemotherapy is administered after surgery to minimize the chance of recurrence (adjuvant chemotherapy) or before surgery in patients with advanced disease and poor prognosis (neo-adjuvant chemotherapy). Managing Metastases In cases with initially inoperable metastases, preoperative chemotherapy can reduce the size of the lesions so patients can be operated on (down staging chemotherapy). The response rate is >50% and in very few cases metastases can even disappear on followup scans, though they will recur in the vast majority if surgery is not carried out. Complete pathological response where the whole tumour is killed by chemotherapy is a rare event which occurs in no more than 10% and should not encourage a wait and see attitude. Chemotherapy Regimes Regimes commonly comprise a combination of drugs, often including 5-fluorouracil with Oxaliplatin (FOLFOX) or Irinotican (FOLFIRI). More recently, biological agents, such as monoclonal antibodies, have been introduced in with a greater response rate. The commonest ones are Bevasuzimab and Cetuximab. An ongoing trial, the New EPOC, is recruiting patients who are randomly treated either with FOLFOX alone or FOLFOX with Cetuximab.
Enquiry Helpline: 0207 483 5148
Preventing Liver Failure One side effect associated with Chemotherapy is its toxic effect on the liver. A period of at least four to six weeks is required to have elapsed between the end of the treatment and extensive resections, to prevent liver failure. Promoting Liver Growth In cases where the anticipated proportion of liver to be removed is >70-75%, it is possible to increase the volume of the remnant by blocking the branch of the portal vein supplying the affected lobe of the liver. This causes shrinkage of one side and elicits a regenerative response on the other side (the unaffected lobe). This procedure is called portal vein embolization (PVE). The procedure is normally well tolerated and requires 24 hours hospitalisation. After a period of 4-6 weeks a liver MRI scan is repeated to assess the response prior to surgery. Two-stage Procedure Even combining downstaging chemotherapy and PVE, it’s sometimes impossible to remove all the metastases with one operation and some patients require a “two stage” procedure where two liver resections are performed within three months or so to allow regeneration of the remnant liver and prevent liver failure. In other circumstances, and sometimes to avoid further surgery, it is possible to destroy some of these lesions with local ablation. Different types of energy used to ablate liver tumours include radiofrequency (RFA), microwave, electrolysis and cryotherapy, RFA being the most widely used in clinical practice. The recurrence rate after local ablation is much greater than after surgery, and the success rate is proportional to the size of the lesion ablated. The Extracoporeal Technique Finally, in very selected cases, it’s possible to remove the liver from the abdominal cavity, resect the metastases on the bench and re-
implant the liver. This extracorporeal technique is an exceptional surgical procedure reserved for cases where the major vessels are involved and require vascular reconstruction. Curative Surgery for Liver Metastases With these strategies and a multidisciplinary approach it’s estimated that an additional 10-15% of initially inoperable patients can be offered potentially curative surgery. Unfortunately, a large proportion of cases will never be candidates for liver resection. A recently developed technique called selective intra-arterial radiotherapy (SIRT), has been tested in phase II trials and can be an option for these patients. With this treatment modality, 90Yttrium microspheres are injected into the hepatic artery supplying the liver metastases with the aim to shrink them or halt tumour progression. In a current trial (FOXFIRE), patients are randomised to SIRT alone or in combination with standard chemotherapy and outcomes are awaited. Management of Liver Metastases Although the liver is a common target for bowel cancer, this malignant tumour can also spread to the lungs, lymph-glands, other intra-abdominal organs and to the peritoneum. In the presence of extra-hepatic disease, the management of liver metastases is more complex, as the objective of liver surgery is to eradicate the disease, not debulk it. In some circumstances a staged surgical approach can be appropriate, where liver surgery is followed by lung surgery. The involvement of the lymph-glands and peritoneal spread has been traditionally regarded as a contraindication to liver surgery. Although this remains true for the majority of the patients, there are a number of exceptions where lymph-glands near the liver can be cleared (after successful chemotherapy) and even the peritoneum can be stripped off. summer 2011 practicematters
WELLINGTON IN FOCUS
Setting the standard The Acute Neurological Rehabilitation Unit at The Wellington Hospital is awarded with the prestigious CARF accreditation… The Acute Neurological Rehabilitation Unit at The Wellington Hospital is the largest private unit in the Uk; providing interdisciplinary inpatient rehabilitation programmes to patients aged 18 and over with acquired brain injury, neurological conditions and complex medical disability. The unit is led by our team of specialist consultants, who are among the nation’s leading experts in their field. The therapy and nursing staff work specifically on the unit and include neuropsychology, speech and language therapy, occupational therapy, physiotherapy and dietetics; all are experienced in rehabilitation. The unit has 46 dedicated and purpose designed rooms with multiple specialist treatment areas encompassing four floors. Our patients come from the UK and around the world, in itself a challenge, but our long established rehabilitation team know that it is imperative to adapt our service to meet the cultural and personal needs of each individual. Each patient admitted to the unit receives care tailored specifically to their needs, with the patient and their family at the centre of all decision making. They are considered to be an integral part of the team and are involved in every aspect of developing the rehabilitation Claire Dunsterville and Lesley Pope are presented with the prestigious CARF accreditation
programme, from identifying goals and treatment aims at the time of admission, to planning discharge home. Providing information and tailored education sessions is essential for success and to ensure that achievements are maintained following discharge. We have adapted our care pathway from admission, through to discharge, to ensure that we can provide our patients and families with the level of support that they need - in the format that suits them best. Earlier this spring The Acute Neurological Rehabilitation Unit was awarded a three year CARF accreditation (the highest accreditation from the Commission on Accreditation of Rehabilitation Facilities). We sought accreditation because we are committed to providing quality services to all of our users. Achieving CARF accreditation reassures our patients and their families that they are choosing a unit with a truly patient centred approach, and an outstanding quality of staff and facilities to enable them to achieve their goals and full potential. CARF is an internationally recognised, independent body that evaluates standards in rehabilitation care around the world. Whilst there are many accredited rehabilitation
programmes in America and across Northern Europe there is as yet only a handful in the UK. The accreditation was awarded following a survey by external auditors who assessed compliance with over a thousand standards – covering all aspects of business strategy and practice and most importantly, the delivery of patient driven and centred care. The survey report commended us on our “competent, passionate team of consultants, nurses, therapists and other personnel who are dedicated to providing high quality services to all persons.” The Wellington Hospital Acute Neurological Rehabilitation Unit is the first private inpatient rehabilitation unit to achieve this accreditation. We can now benchmark our services against those of our peers in the UK and Internationally. But this is only the beginning. We will continue to develop our services to ensure that we remain to offer the highest standard of care in rehabilitation. Throughout 2011 and 2012 we will also be establishing a spinal rehabilitation programme which offers the same high quality inpatient rehabilitation programme, to patients who have sustained a spinal cord injury. We are also looking at new assistive technologies which can benefit our patients. This includes the use of robotics to enhance treatment, equipment to increase independence and establishing an environmentally controlled room for assessment purposes. Visit the CARF website at www.carf.org Alternatively contact the Acute Neurological Rehabilitation Unit if you would like further information. Call 0207 586 2462
Visit the CARF website at www.carf.org Alternatively contact the Acute Neurological Rehabilitation Unit if you would like further information. Call 0207 586 2462
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The Respiratory Unit
Offering patients a seamless service The Respiratory unit at The Wellington Hospital offers your patients a seamless service. As many of you will be aware, the lung function laboratory, managed by Damian Muncaster, is available five days a week and offers all lung function tests from basic spirometry to cardio-pulmonary exercise testing. Damian runs an educational programme for the nurses at The Wellington Hospital, and this service extends to the wider community. He also provides education in spirometry for practice nurses and anyone else who wishes to attend. We feel that this academic programme is an essential part of the Respiratory unit’s function. All consultants in the unit are fully accredited in respiratory medicine, and offer both general and specialist services. In the forthcoming months, they will be writing articles in Practice Matters for you to learn more about their subspeciality interests. This article will outline the services provided to our local GPs, and anyone else who wishes to refer patients in to us.
We accept referrals for all areas of respiratory medicine, including: • Cough • Asthma • Bronchiectasis • Sleep related problems • Haemoptysis • Possible Lung Cancer • Evaluation of the breathless patient and all other respiratory conditions Cancer Care As you may have read in previous Practice Matters, our new cancer unit at the Platinum Medical Centre is in partnership with Leaders in Oncology Care (LOC). We have a team of specialists who are skilled in the investigation and treatment of patients with a suspected diagnosis of lung cancer.
Investigations We offer fibre-optic bronchoscopy, endobronchial ultrasound (EBUS), percutaneous biopsy, the full modality of radiological imaging techniques, and specialist cardiothoracic and thoracic surgeons. These services are in addition to dedicated pathology services. Education Each consultant in the Respiratory unit is available to come along to individual GP surgeries to talk on topics of your choice. For more information please contact Lung Function Lab manager, Damian Muncaster on 0207 483 5360. To arrange a referral contact the Enquiry Helpline
out Patient Services The team are based in the new Platinum Medical Centre, where we have close links with Leaders in Oncology care (LOC) and the centre’s state-of-the-art facilities. You are able to refer patients with respiratory problems to see members of the unit on a daily basis. For referrals, please contact the Enquiry Helpline team who can organise the appointment for your patient. Alternatively, you can fax or email your referral letter through (our email system is encrypted and maintains patient confidentiality).
All consultants in the unit are fully accredited in respiratory medicine, and offer both general and specialist services Enquiry Helpline: 0207 483 5148
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WELLINGTON IN FOCUS
Thyroid and Parathyroid Disease:
AN INTEGRATED APPROACH The role of the thyroid and parathyroid has been understood over the last two centuries. Dr Stephen Robinson and Mr Neil Tolley, reviews the history and management issues of these endocrine organs and the options available today…
Robert Graves was a great linguist. When imprisoned for espionage in Austria he was released when it was felt his German was so good, that he could not possibly be a spy. However, he gave lectures in the then medically unfashionable English rather than Latin, he wanted his students to understand. He also believed students should attend the wards and experience medicine rather than hear medicine in lectures. In 1835 he described exophthalmos with goitre, although described by Basedow around the same time in 1840, Graves’ disease has stuck in the English speaking world. The adage amongst physicians, as well as old wives, was “to feed a cold and starve a fever”. We don’t know how much he had anticipated about the importance of the dangers of catabolism but Graves wanted his epitaph to read “I fed fevers”. Functional thyroid disease is common; up to 2% of the population will have an episode of thyrotoxicosis at some stage in their life. Symptoms may include any system in the body; untreated it is a major cause of morbidity and mortality particularly through atrial fibrillation and osteoporosis. The cause of thyrotoxicosis needs to be ascertained, (Graves’ disease being the most common) and then a treatment plan formulated. The heart should be protected with beta-blockade whilst the slower antithyroid drugs begin to work. Definitive treatments include thionamides, radioiodine and surgery. The ideal option will vary from patient to patient depending on their wishes and family situation. Hashimoto Hakaru described lymphomatous goitre before his travels to Europe. He returned to Japan with the beginning of the first World War, becoming the town doctor. George Redmayne Murray had pioneered the use of thyroid extract in 1891, it wasn’t for 40 years that purified thyroxine was developed. Hypothyroidism is not such as threat to life as thyrotoxicosis, although myxoedema is happily rare in the present era. Treatment is usually relatively straightforward, titrating thyroxin to normalise thyroid stimulating hormone (TSH) levels. It is particularly important to keep TSH normal before and during pregnancy. Hypothyroidism during pregnancy is associated with suboptimal
www.thewellingtonhospital.com Dr Stephen Robinson, is a Consultant Endocrinologist Mr Neil Tolley is a Consultant ENT surgeon Both work at St Mary’s and The Wellington Hospital
childhood developmental IQ, even at a level without maternal effects. We now have a clearer evidence base on the benefits of adequate treatment of hypothyroidism during pregnancy. Fuller Albright was attracted to internal medicine with the discovery of insulin when he was 22 years of age. He described the types of hyperparathyroidism separating a single adenoma from four gland hyperplasia; also showing the association with renal stones. Primary hyperparathyroidism (PHPT) is common maybe affecting 1:500 individuals. It is usually asymptomatic, contrasting with the original descriptions. Most patients are now found incidentally, but it is an important and treatable cause of osteoporosis. Patients need a definitive diagnosis and the exclusion of other conditions such as hypovitaminosis D, hypocalciuric hypercalcaemia and multiple endocrine neoplasia. The management of PHPT will depend on age, complications and severity. Therefore present hypercalcaemia or previous disequilibrium hypercalcaemia, renal stones or nephrocalcinosis and reduced bone mineral density all contribute to the need for treatment. Medical therapy is available but response is variable; in addition pharmacotherapy controls rather than cures the condition. Definitive treatment is surgical and can now be achieved through the minimally invasive approach. Nodular thyroid disease is common, affecting over 10% in some populations, depending on iodine intake. In an iodine replete population aged 30-59years 4.2% have palpable nodules; many more have smaller thyroid nodules. Many with benign thyroid mass disease require surgery in order to confirm a diagnosis, to protect the airway or for cosmesis. Thyroid cancer is relatively uncommon 3.7-4.7/100,000 per annum. Thyroid cancer is mostly associated with a normal lifespan if diagnosed and treated appropriately; that treatment needs a multidisciplinary approach. Mr Neil Tolley as chair of Imperial thyroid cancer multidisciplinary team and Dr Stephen Robinson as the Chair of the
North West Thames Thyroid cancer Tumour working group together with radio and cross sectional imaging specialists, cytologists and pathologists, and oncology have worked together for over 10 years to deliver an integrated approach for these patients.
online and Daily Mail. The system has certain advantages listed in box 2. Unfortunately, robotic thyroidectomy isn’t a viable treatment option for everyone, but as the technique improves more people may be able to have this surgery.
In 1850 thyroid surgery was banned in France and described as “horrid butchery” by one Philadelphian Professor. The pioneers of early Thyroid surgery had a tempestuous experience with mortality rates in excess of 50% during the 19th century. This was hardly surprising in an age without anaesthesia, antiseptic principles and even basic diathermy. Furthermore, the function of the thyroid gland was unknown and the parathyroid glands hadn’t even been discovered! Even in the early 20th century the thyroid was considered to be a lubricator of the vocal cords and goitre was synonymously referred to as bronchocele.
BOX 1 Why is it called ‘Robotic’?
Emile Theodore Kocher was a Swiss surgeon and is rightly regarded as the father of modern thyroid surgery. By performing meticulous surgery, aided by antiseptic principles and anaesthesia he was able to reduce mortality to 4.5% in his first 2000 thyroidectomies. He was the first surgeon to receive a Nobel prize for his remarkable work in 1909. By performing a subtotal thyroidectomy he was able to minimise hypothyroidism. Yet at the same time minimise risk to recurrent laryngeal nerves and death by tetany. The Kocher incision, although superseded by improved incisions is still used by many surgeons worldwide.
• Console: The surgeon sits at the console, controlling the four robotic hands and sees images from the 3D camera. The surgeon’s hand movements are seamlessly translated by state-of-the-art robotic and computer technologies into precise movements of the instruments.
There have been significant advances in thyroid and parathyroid surgery during the last 10 years. Robotic assisted thyroidectomy facilitates a minimally invasive technique to remove all or part of the thyroid and was first developed in South Korea (box 1). It is also called robotic thyroid surgery or robot-assisted endoscopic surgery; the scars are in the axilla rather than the neck. Mr Neil Tolley pioneered the technique in the UK whilst performing rigorous clinical research to evaluate robotic assisted head & neck surgery as part of an ethically approved clinical study. Their work has been reported in The Independent, BBC
This refers to a sophisticated platform called the da Vinci Surgical System which is required to perform robotic-assisted surgery. It is completely controlled by the surgeon who uses it to perform the operation. • Four arms: These hold tiny instruments which are controlled by the surgeon, allowing for very precise movements. • 3D camera: This is a high-definition camera that gives the surgeon a 3D view of the operating field. This can zoom in if an even closer view if required.
BOX 2 Advantages of the telerobotic approach; • Better view and identification of critical structures: The 3D camera gives a magnified view and enables the surgeon to clearly visualise the thyroid and adjacent structures • Better dexterity in certain areas: The robotic instruments give the surgeon enhanced dexterity which enables manipulation of certain portions of the thyroid more easily. • Avoidance of a visible neck scar; the scar is hidden in the armpit which translates to superior cosmetic results. This is the biggest benefit. • Reduced post surgical numbness affecting the front of the neck
WELLINGTON IN FOCUS
MeTAl on MeTAl The use of metal bearing surfaces in hip replacement is not new – in fact they precede the metal on polyethylene design of Sir John Charnley. These early metal on metal (MoM) designs were problematic as the manufacturing process was not precise enough. A few of them (those that happened to be made just right) lasted very well, but many ended up with the head too large for the socket so they clutched and pulled the socket out. As the low friction Charnley arthroplasty seemed to work so well, the MoM designs faded away. However, the Charnley hips proved to have problems too: in particular the polyethylene sockets wore out and they generated large numbers of particles. These were then ingested by macrophages which became activated – inducing bone resorption. A search for alternative bearings led a return to the use of MoM designs. These so called second generation MoM hips were manufactured to far more exacting standards, though they have not been without their problems and they remain an area of particular interest and controversy amongst arthroplasty surgeons. Metal Bearing - Advantages The major advantage is a decrease in wear rate – the volume of wear is hundreds of times smaller than with polyethylene cups. This allows the potential for far longer-lasting hips and reduces the problems of osteolysis and loosening. In metal on plastic designs the rates of wear are increased significantly when the head size increases. When using a large MoM design, there is actually less wear than with smaller head sizes. This encourages the use of larger head sizes - which helps with stability of the hip and reducing the incidence of dislocation. Metal Bearings - Disadvantages Although the volume of particles produced by wear is much lower, there are higher numbers of very small particles. Though they
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Hip ReplACeMenTS do not cause osteolysis in the same way as polyethylene particles they are associated with a lymphocytic response, which can lead to localised and generalised problems. The local hypersensitivity reactions can lead to pain, inflammation and pseudotumours: this can be destructive and lead to major revision surgery. The generalised concerns include the potential for toxicity and carcinogenesis. There is a ‘wearing in’ process for MoM hips so they actually produce a higher number of particles in the first year after implantation than later on. The second significant disadvantage appears to be their increased sensitivity to operative technique and positioning. Whilst a conventional hip replacement will function well across a wide range of implantation angles, a MoM hip is far more sensitive and if implanted at the wrong angle is likely to fail. In addition, their behaviour is related to the size of the implant: smaller sizes are associated with higher failure rates. Implant designs There are two main forms of MoM bearing hip: hip resurfacing and large diameter stemmed implants. Both use alloys of cobalt with chromium, being hard wearing and relatively easy to manufacture.
The so called ‘third generation’ of MoM hips was the emergence of hip resurfacing in the 1990’s, most noticeably the Birmingham Hip Replacement. The concept of resurfacing is to conserve bone in the proximal femur; this allows more normal mechanical function and makes revision surgery, if needed, less complex. Although, this operation takes a little longer than a total hip replacement, and usually requires a slightly larger scar. It relies on the femoral head being intact (i.e. not too full of cysts) and the femoral neck being in the normal alignment. As the cup is uncemented and there are no screw holes to augment fixation, the acetabular anatomy needs to be relatively normal too. The large diameter stemmed concept - is more similar to conventional total hip replacement on the femoral side, articulating with a resurfacing type acetabular component. A large metal head is attached to the femoral component so it provides the same large bearing surface with attendant advantages of stability. Despite seeming an attractive compromise, the rates of failure are worryingly high and I do not personally use them at present. There have been problems with designs in both sub-types; interestingly, many of these issues
Mr Jonathan Miles is a Consultant orthopaedic Surgeon at The Royal National orthopaedic Hospital and The Wellington Hospital
have been with the cup design. The ASR cup (Depuy) has been withdrawn due to high rates of failure and patients with this implant are recommended to have close follow-up and consider revision in cases of unexplained pain. The MoM stemmed implants are showing very high rates of revision in The National Joint Registry and the British Hip Society have expressed their concerns over using this type of implant. Who should have a MoM hip? I believe that there is still a place for hip resurfacing: younger men with normal anatomy and without inflammatory arthritis are still appropriate. With the choice of a well performing implant, like the Birmingham (Smith & Nephew), these patients can be highly satisfied by resurfacing as long as the surgeon is familiar with its use and limitations. I do not currently see a role for stemmed metal on metal implants in patients. What should I do with patients with problems with a MoM hip? Patients usually present with unexplained pain around the hip. This can be in a hip that was ‘never right’ or preceded by many years of success. There can be gross signs of failure, including neck fracture, dislocation or extensive soft tissue damage with loss of function. They should be referred to a surgeon experienced in metal on metal revision surgery. In the absence of obvious problems, the patient will need an MRI scan to check for soft tissue damage and pseudotumour, a CT scan to check the alignment of the components and blood tests to check cobalt and chromium levels. Unfortunately, many of these patients will require revision surgery to remove the metal on metal bearings.
Enquiry Helpline: 0207 483 5148
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The Wellington Hospital is dedicated to supporting Gps
SPOTLIGHT ON: The GP Liaison Team The GP Liaison team is a group of four officers and five assistants, who support GP surgeries around London and the surrounding areas. Their aim is to provide a bespoke service for you and your patients – ensuring a smooth and comfortable patient journey at all times. This support service ranges from answering your queries and organising appointments, to arranging educational events and keeping you up-todate with the hospital’s developments. If you haven’t yet met a member of the GP Liaison team here is a chance to hear about the selection of the services they offer, and how this service can help you. over the next few issues we will be taking a closer look at the individual GP Liaison officers and the specific areas in London that they focus on…
katy Cross CENTRAL LONDON OFFICER Hello all Central London GPs! My name is Katy Cross and I have been based at The Wellington Hospital for nearly two years. As a GP Liaison Officer I have a number of responsibilities, but ultimately I am here to support GPs and assist in any way I can. I am more than happy to help with all your queries – whether they are patient referrals, general enquiries, or maybe you would like a seminar at your practice? (I’ll even bring lunch!) There is so much activity here, with our new Platinum Medical Centre which opened in May, that I realise it can be hard for professionals outside – to keep up! This is where I come into my element. I am dedicated to keeping you informed and up-to-date with all our new services, To contact katy Cross: Tel: 07826 551 318 Email: email@example.com
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new technology and the diverse range of educational events we offer.
katy Cross GP Liaison Officer for Central & South West London
Recently my role has evolved to encompass physiotherapy support in and around London too. On the 16th June we held our second physiotherapy networking event in The Wellington boardroom with a selection of orthopaedic consultants. This event is a fantastic platform to create new relationships with our consultants and I hope to arrange more for the future. If you are a GP or practice manager in the Central or South West London area, and would like more information about the hospital, or the services the GP Liaison team offer, please contact me. I look forward to working with you in the future. To contact The Wellington GP Liason Team: Tel: 0207 483 5148 Fax: 0207 483 5618 Email: wellington.enquiryhelpline@ hcahealthcare.co.uk
I am here to support GPs and assist in any way I can www.thewellingtonhospital.com
Within the HCA group, a number of our sister hospitals have a huge online presence, in particular The Portland Hospital, who interact with their audience via a lively twitter feed and an engaging topical blog. The Wellington Hospital has now decided to venture into this new territory… If you enjoy our Practice Matters GP Magazine, then The Wellington Hospital blog is definitely a space you need to browse. Our blog offers information on common medical conditions through to more complex information for GPs and other healthcare professionals. Meaning it’s a something that both you and your
We even provide Podcasts from some of London’s most eminent consultants, tours of our hospital facilities and charity endeavours on our YouTube channel: The Wellington Hospital. If you’re already part of the social networking community join us on our Facebook page or follow us on Twitter @WellingtonHosp where you’ll receive regular updates about the hospital, whether that’s information on new technology, innovative treatments or details of our educational events - even if you’re not fully active in this medium, why not come and have a little read of our articles on The Wellington Hospital blog.
Postgraduate activities Each month The Wellington Post Graduate Education programme holds at least four education sessions, which include regular seminars and masterclasses interspersed with symposia and study days. The Orthopaedic Masterclasses, held at London Zoo, attracts participants of up to 200 people and take place monthly on a Tuesday evening. These lively presentations are given by our specialists on subjects that encompass the entire orthopaedic spectrum. Topics for the remainder of the year include: The Management of Knee Problems 2011 (20th September), Lumbar Spine Surgery Options (18th October), Advanced Management of Sport Related Conditions: Innovation and Evidence (15th November) and Update on the Management of the Painful Hip (6th December). In October we resume our GP seminars in the Boardroom at The Wellington South. These feature all specialities covered by consultants practicing at The Wellington and are held in the evening on the first Thursday of every month.
Enquiry Helpline: 0207 483 5148
We look forward to talks in Urology, Cardiology and Endocrinology. A similar series for GPs is also held at the Wellington Diagnostics and Outpatients Centre in Golders Green. A Certificate of Attendance will be provided at all seminars, which delegates can use towards CPD. If you have missed any previous talks, some of these are now available on line, just visit www.thewellingtonhospital.com and search ‘GP Webinars’. Keep an eye out on our website, as we are adding webcasts of our talks - as soon as they become available. Some of the education highlights include Mr Barry Paraskeva’s SILS live surgery, which you can watch in full. We are already well ahead in planning educational events for 2012 - a year that will include new treatments for cancer and robotic surgery amongst others. Dr Martin Sarner
The GP Liaison team have teamed up with The Wellington’s Consultant Liaison team to offer referring medical staff a menu of talks in addition to The Wellington’s existing event schedule. Breakfast, Lunchtimes or Evenings talks are available and can be held either in our boardroom or at your own practice. To arrange a talk call The Wellington Enquiry Helpline or visit the Medical Professionals section on The Wellington Hospital website at www.thewellingtonhospital.com Consultant Cardiology Dr A Chow Dr A Ghuran Colorectal Mr C Elton Mr A Obichere Dermatology Dr S Mansoor ENT Dr H Kariyawasam Prof S Saeed Gastroenterology Dr C Onnie Dr V Wong General Medicine Dr A Qureshi Dr J Birns Gynaecology Prof E Downes Liver Mr G Fusai Nephrology Dr M Wahba Prof A Warrens Neurology Dr D Heaney ophthalmology Mr H Zambarakji orthopaedics Mr N Cullen (Foot & Ankle) Mr J Miles (Hip & Knee) Prof E Schilders (Hip) Mr N Toft (Hand & Wrist) Plastics Mr N Toft Respiratory Dr M Beckles Dr B O’Connor Sports Medicine Dr C Speed Urology Mr R Hamid Dr J Ockrim Vascular Mr C Bicknell Mr H Flora
Healthcare in particular has thrived through various social media platforms, allowing patients and healthcare professions to keep up-to-date with the very latest medical developments.
patients can benefit from; making healthcare information accessible for everyone. We will include articles from a selection of our consultants, who also work at leading NHS hospitals in London, alongside patient case studies, hospital news and service updates.
Social media has revolutionised the way in which the modern world communicates. What we say online is now instantaneously accessible to a those who want to listen and has the potential to deliver, what was once reserved for a select few people and institutions, out to a worldwide audience.
Consultant led Talks
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Technology at The Wellington Hospital Technology is a huge priority at The Wellington Hospital, we believe that investing in state-of-the-art technology improves standards of diagnostics, treatment and patient care. To help us to continue to offer our patients the very latest in technology we were joined by Debbie Lang, New Technologies Manager. We had a quick chat with Debbie to talk about her new role, and what new technologies we can expect to see at the hospital in the future. PM: Tell us about your role as New Technologies Manager: DL: Following the acquisition of the daVinci Surgical Robot it was decided that The Wellington Hospital needed a dedicated person to project manage and promote new technologies, and hence the role of New Technologies Manager was born! The role is very varied and includes, establishing and maintaining a Robotics Group and pathway with close attention to governance, project managing the new Breast programme, promoting Endo-bronchial Ultrasound, PET/CT, Cardiac MRI, CIRC..…..everyday is different! PM: What did you do before you came to The Wellington? DL: I qualified as a diagnostic radiographer in Edinburgh in 1999, did a post grad in MRI in 2002 and since 2005 have been in Sales and Marketing roles with GE Healthcare, Nuffield Diagnostics, and Alliance Medical.
In 2010 I decided to undertake a part-time post grad Marketing diploma through the chartered Institute of Marketing which I complete later this year. PM: What do you enjoy most about your new role? DL: The variety of the job! And the fact that I am always learning about new developments and acquiring new skills. PM: What new technologies are The Wellington looking to invest in, in the future? DL: The Wellington has just invested in a new 3T MRI scanner & is about to invest in innovative technology for its new Breast Cancer Unit. After that, maybe Lithotripsy. PM: If you weren’t New Technologies Manager, what would you be? DL: In another life I’d like to be an Interior Designer!
Educational events scheduled for September and October are outlined below. For further information and booking details please see our website: www.wellingtonevents.co.uk 14.9 Respiratory – Lord’s Cricket Ground 17.9 North London WDoC Seminar, Gastroenterology – TBC 20.9 GP Seminar, Nephrology – WDOC Golders Green 20.9 orthopaedic Masterclass 8: The Management of knee Problems 2011 – Huxley Lecture Theatre, London Zoo 28.9 Resuscitation Training – Boardroom, South Building 01.10 Radiology and Technology Workshop Day – Lord’s Cricket Ground 06.10 GP Seminar: TBC – Boardroom, Wellington South 12.10 Neurosciences 2 – Lord’s Cricket Ground 18.10 orthopaedics Masterclass 9: Lumbar Spine Surgery options – Huxley Lecture Theatre, London Zoo 25.10 GP Seminar, Vascular – WDOC Golders Green 26.10 Resuscitation Training – Boardroom, South Building The Wellington Breakfast Club seminars will begin in October. More information will be sent to you when our educational programme returns in September. Monthly seminars will be held at Café Med, St John’s Wood 7.45pm – 8.30am. We hope to see you there!
NEW CONSULTANTS Dr Ivor Daniel Baron, Sports Medicine Physician, King’s College Hospital Mr Rajarshi Bhattacharya, Consultant Trauma & Orthopaedic Surgeon, St Mary’s Hospital, Praed Street
Mr Timothy Briggs, Consultant Urologist, Barnet Hospital Mr Shehan Hettiaratchy, Consultant Plastic Surgeon, Charing Cross Hospital Professor Marjan Jahangiri, Professor of Cardiothoracic Surgery, St George’s Hospital
www.thewellingtonhospital.com Enquiry Helpline: 0207 483 5148
Dr Alexandra krichevskaya, Consultant Paediatrician, Royal Free Hospital Dr Nisith Sheth, Consultant Dermatologist, Guy’s & St Thomas’ Hospital Mr Simon Woodruff, Consultant Ophthalmic Surgeon, Addenbrookes Hospital