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What is Endocrine Surgery?
Endocrine surgery is surgery that is done on the endocrine glands of body. These are the thyroid, parathyroid and adrenal glands.
A condition called familial Endocrine Neoplasia is also treated by experts in endocrine surgery.
With advances in minimally invasive surgery, laparoscopic and robotic surgery, as well as advances in nuclear medicine and diagnostic technologies, management of conditions of the endocrine glands has become more safe.
What are parathyroid glands? What is hyperparathyroidism?
We have 4 parathyroid glands, secreting parathyroid hormone, or PTH. PTH helps to control blood calcium levels.
An overactive parathyroid gland is called hyperparathyroidism. The most common cause of hyperparathyroidism is a parathyroid adenoma in a single gland. Hyper-functioning of parathyroid gland may also be caused by kidney diseases, vitamin D deficiency, or genetic conditions. The diagnosis of hyperparathyroidism is made based on blood levels of calcium and PTH. Vitamin D levels are also important when the diagnosis of hyperparathyroidism is considered and will affect its management.
What are the types of Parathyroid Surgery?
Focused or mini-invasive parathyroidectomy
Minimally invasive parathyroid surgery is performed through very small neck crease incisions (1 to 1½ inches). The incision is almost invisible when closed by a sutureless technique.
Before the diagnosis is made it is important to localize the hyper-functioning parathyroid gland by nuclear medicine scans and ultrasonography. Excision of the gland is confirmed measuring the PTH levels intraoperatively.
Bilateral Neck Exploration
In case localization facilities are not available in a hospital or in cases with multi-glandular parathyroid diseases, all four parathyroid glands are explored to remove the diseased gland. Typically performed through a neck incision, 5 to 6 inches long, all four glands are explored during surgery.
What are the symptoms of hyperparathyroidism?
As medical students are taught, symptoms of hyperparathyroidism should be remembered with the mnemonic of stones, bone and groans. Calcium stone in the kidney, bone pain due to bone loss or osteoporosis and abdominal cramps, peptic ulcer and altered bowel habits. Physicians should have a high level of suspicion and consider the presence of hyperparathyroidism when these symptoms are present. Patients reporting with such symptoms should have a serum calcium level with PTH ordered.
What is an adrenal gland? What hormones does it produce?
There are two adrenal glands as part of our endocrine system, located just above each kidney. They are very small glands but several important lifesaving hormones are produced by them.
Medical mnemonic sugar, salt and sex, defines cortex of adrenal gland, As one moves layers into the adrenal cortex, compounds that control salt, mineralocorticoids, aldosterone, control sugar, glucocorticoids, cortisol, and sex hormone, androgens are produced. Adrenal medulla is source of Catecholamine, such as: epinephrine (adrenaline), norepiniphrine, and dopamine - affect heart rate and blood pressure.
Aldosterone - regulates salt balance and blood pressure, Cortisol - controls immune system, metabolism, salt balance and response to other hormones, Small amounts of androgens & estrogens are Sex hormones.
What is a Pheochromocytoma?
A pheochromocytoma is an adrenal tumour that secretes catecholamines (i.e. adrenaline & Nor-adrenaline). When bursts of catecholamines are secreted, patients often have symptomatic spells of High blood pressure, Palpitations, headache, panic attacks, Flushing, sweating and finally Fatigue, that lasts up to an hour.
What is Cushing's Syndrome?
Cushing's syndrome is excessive amounts of cortisol secretion by adrenal glands. The symptoms are High blood pressure, Weight gain, Fatigue, Acne or facial hair, truncal obesity, i.e. rounding of the face and Buffalo hump (fat pad at back of neck), Straie (purplish stretch marks on the skin), Elevated blood sugars.
There are many potential causes of excessive cortisol, and extensive testing is needed for diagnosis. There is considerable variation in steroid production throughout the day. Adrenalectomy may be performed to remove one or both adrenal glands, depending on the cause of cortisol excess. After surgery most patients require additional steroids that are tapered over several months.
What are advances in Surgery of adrenal gland?
Laparoscopic adrenalectomy has almost replaced open operation with large 8 to 10 inches for adrenal. Laparoscopic adrenalectomy involves making 3 or 4 very small incisions of 1 to 1½ inches and removing the adrenal gland using a telescope, laparoscopic instruments and advanced energy devices. There is drastic reduction in pain and morbidity due to laparoscopic procedure with early recovery. Patients after laparoscopic procedure could be discharged within 48 hours of admission. Jaslok hospital is equipped with surgeons and instrumentations to offer laparoscopic adrenalectomy to almost all patients.
What is Multiple Endocrine Neoplasia (MEN) Syndromes & their treatment?
Multiple endocrine neoplasia syndromes are endocrine disorders related to genetic mutation, manifested as tumours of various endocrine glands in combination.
Types, MEN 1, MEN 2, FMTC
MEN 1 frequently involve tumours of the parathyroid glands, the pituitary gland, and the pancreas. Tumours in these glands can lead to the overproduction of hormones. The most common presentation of MEN 1 is hyperparathyroidism.
MEN 2 A is associated with a form of thyroid cancer called medullary thyroid carcinoma. Some people with this disorder also develop a pheochromocytoma, which is an adrenal gland tumour that can cause dangerously high blood pressure and hyperparathyroidism
MEN 2B is also associated with medullary carcinoma thyroid, pheochromocytoma and mucosal neuromas.
FMTC, familial medullary thyroid carcinoma
The treatment of these conditions is by multidisciplinary approach involving various specialities. Jaslok hospital is well equipped to offer comprehensive treatment for such conditions.
What is Thyroid Goitre or enlargement?
Enlargement of the thyroid is called goitre and lumps within it are called thyroid nodules. They may be obvious to the naked eye or can be found incidentally by imaging studies of the neck, such as a sonography of neck. Most goitres and thyroid nodules will not interfere with a person's health.
When thyroid goitre needs surgical attention?
Goitres and thyroid nodules needs surgical attention if they cause symptoms or cosmetically unacceptable for the patient.
1. Large goitres could become uncomfortable and cause breathing, swallowing difficulties, airways, esophagus constriction or blood vessels obstruction.
2. Thyroid nodules that have an indeterminate diagnosis or suspicious for cancer need surgical attention.
3. Nodular goitre causing hyperthyroidism
What is a Thyroid Nodule?
A thyroid nodule is simply a lump or mass in the thyroid gland. Thyroid nodules are relatively common; that can be felt on examination or sonographic imaging. Thyroid nodules are evaluated by sonography, aspiration cytology, thyroid function tests and treated accordingly.
What are the causes of Thyroid Goitre?
Physical and physiological strain on body metabolism, iodine deficiency, certain drugs such as lithium carbonate, genetic mutation for the proteins that permit the thyroid gland to make thyroid hormone, typically develop a thyroid goitre.
Inflammation of the thyroid gland (thyroiditis) can produce gland swelling, such as autoimmune thyroiditis and painless postpartum thyroiditis. Autoimmune thyroiditis (Hashimoto thyroiditis) occurs when a person's immune system turns against their own thyroid gland, causing thyroid inflammation. Progression of these conditions leaves thyroid permanently under active.
What are symptoms of Hyperthyroid?
Loss of weight, heat intolerance, tremors in hands, palpitations, insomnia, anxiety, increased frequency of bowel movements or diarrhoea.
What are symptoms of Hypothyroid?
Weight gain, cold intolerance, constipation, very dry skin, slowed thinking, depressed mood,
Risk factors for thyroid cancer
What are advances in Thyroid surgery?
Convention surgery, video-scopic surgeries, minimally invasive surgeries and robotic surgeries, there are tremendous advances in thyroid surgeries. Highly precise energy sources, magnified viewing loops, ultrasonic devices have made thyroid surgery safer and effective.
Collar incision in neck is till date cosmetically the best incision offered in thyroid surgery. With sub-cuticular stitching and post operatively wound care this neck incision is almost not detectable after surgery.
Videoscopy in thyroid has very limited scope for unilateral small thyroid lesions; minimally invasive thyroid surgery reduces neck incision length. Robotic surgery through axillary incision is still evolving.
What is post-operative care in thyroid surgery?
Two important structures, recurrent laryngeal nerve and parathyroid glands are in close proximity to thyroid, and special precautions are taken to prevent injuries to these structures. Post operatively patients are monitored for such complications and treated accordingly. Major complications are negligible and correctable by proper post-operative care.
What about thyroid supplement after surgery?
Not all patients need thyroid supplement; small amount of thyroid gland is enough to take care of body’s requirement. Those patients, who need Thyroid hormone or thyroxin supplement, find no change in their routine lifestyle.
What about scar after surgery
Neck scar is almost not visible and is hidden in neck crease. Stitches in thyroid surgery are absorbable and placed subcuticular, not visible on skin. They dissolve by themselves in body in course of 2 to 4 weeks. Postoperatively avoidance to sun exposure and operative placement of scar in neck crease and technique of wound closure leaves behind no scar after surgery.
ENDOSCOPIC SKULL BASE SURGE
For certain conditions in the brain that are located at the base of the skull such as a pituitary tumor or tumors located towards the front of the brain, surgery may be possible endoscopically.
The treatment for these conditions is provided by a multidisciplinary team of neurosurgeon, ENT surgeon, ophthalmic surgeon and endocrinologist.
The treatment involves a type of surgery that is carried out through the sphenoid sinus, which is located directly behind the nose. Using this method, the doctor does not enter the brain cavity itself. This approach is called the Endoscopic Endonasal Approach.
Under anaesthesia, your surgeon will place an endoscope which has a very small diameter through one nostril. The endoscope has a powerful camera at the end of it which allows the surgeon to view the area directly. With the help of micro-instruments inserted through either nostril, the surgeon will carefully remove your tumor after which the floor of the skull base is repaired and the endoscope is removed. The endoscope allows the surgeon to see the areas around the tumor as well.
The Endoscopic Endonasal Approach allows surgeons to treat many hard-to-reach tumors, even those once considered "inoperable," without disturbing the face or skull.
Being less invasive than traditional open surgical techniques it results in faster recovery and less pain.
At Jaslok Hospital, these surgeries are performed by a team of experts in dedicated and state-of-the-art operation theatres that incorporate sophisticated imaging technology.
The concept of team surgery has allowed our centre to expand the role of the Endoscopic Endonasal Approach (EEA) to include all pituitary tumors, regardless of size or invasiveness, and to access tumors of the skull base from the sphenoid sinus all the way down to the upper cervical spine and out to the cavernous sinus, Meckel’s cave, jugular foramen and beyond.
In addition, our center has experience with these techniques for pediatric patients as well as for challenging lesions such as aneurysms and angiofibromas.
These are some of the growths and conditions that may be treated by skull base surgery:
You may have many possible symptoms arising from a growth or abnormality in the skull base area. Symptoms will depend on the size, type, and location of the growth or abnormality, and may include:
The diagnosis of growths or abnormalities that may require skull base surgery is based on your symptoms and a physical exam. Because this area cannot be seen directly, these exams and imaging studies are important parts of the diagnosis:
After skull base surgery, you will be closely cared for by your medical team. Some people need continued therapy, and many will need repeated testing to make sure that a growth is not coming back over time.
Area of expertise
Surgery of pituitary tumour.
Surgery of Acoustic tumours.
Surgery of other Cerebello-pontine tumours like Epidermoids,meningiomas.
Surgery of spinal problems like spondylotic disease, intervertebral disc disease,spinal tumours and spinal trauma.
Surgery of cerebral, cerebellar and spinal
Brief write up
Dr. Nagpal was the first neurosurgery graduate of Bombay University and the Seth G.S. Medical College and K.E.M. Hospital. He completed his neurosurgical training in 1968 and has been in practice since then. Dr. Nagpal was the first neurosurgeon in Mumbai to perform trans sphenoidal pituitary surgery.
MS General Surgery.
Dr. Nagpal has been the guest of honor at various national and international conferences
He has special interest in Skull base surgery. He is trained in operating complex Cranio-vertebral abnormalities and skull base tumors like acoustic shwannoma, pituitary adenomas and skull base meningiomas.
Dr. Ramdasi is currently a Consultant in Neurological Surgery at the Jaslok Hospital and Research Centre since 1 year. He has completed his neurosurgical training from Seth G.S. Medical Collage and KEM hospital one of the best institutes in India.
"2nd Rank in the university in Mch exam 2013
Got Best paper awards at various national and international conferences.
Has published over 25 peer reviewed journal articles in international journals.
Has renowned research in complex Cranio-vertebral junction abnormalities and rare brain tumors. "
General Neurosurgery, traumatic brain injury, brain and spinal cord tumors, treatment of degenerative disc disease, intracranial aneurysms, arteriovenous malformations, arteriovenous fistulae
Dr. Pandya is a neurosurgeon and academician par excellence. He was a faculty at the Department of Neurosurgery, K.E.M.Hospital and Seth G.S. Medical College from 1968 – 1998. Following his superannuation as the Proessor of Neurosurgery in 1998, he joined the department of Neurological surgery at Jaslok Hospital and Research Centre as a senior consultant in neurological surgery.
Awards and recognition:
1. Lifetime achievement award, Neurological Society of India
2. Lifetime achievement award, Bombay Neurological Society
3. Lifetime achievement award, Indian Journal of Medical Ethics and National Bioethics Conference.
4. Guest of honour, National Conference of Indian Society of Neuroanesthesiology and Critical Care 2018
5. Guest of honour, ACNS Neurosurgical Seminar, Institute of Neurosciences, Kolkata, February 2018.
"Dr. Ambekar is currently a Consultant in Neurological Surgery at the Jaslok Hospital and Research Centre. Previously, he graduated cum laude with a M.B.B.S. from JIPMER, Pondicherry, which is one of the primer institutes in India. He completed a 5-year neurosurgical residency at NIMHANS, which is the best University for training in Neurosurgery in India, followed by a 1- year skullbase surgery fellowship and a 2-year endovascular fellowship at the LSUHSC, Shreveport, LA and the University of Miami Department of Neurological Surgery, United States. Dr. Ambekar specializes in the treatment of brain aneurysms and AVMs (arteriovenous malformations).
He is one of the few dual-trained neurosurgeons in the country able to offer both surgical and minimally invasive endovascular solutions to complex cerebrovascular disease. The minimally invasive endovascular techniques allows for patients to be treated through a 1mm incision in the leg with no incisions in the head. Because of his dual training, he unbiased with regards to the treatment chosen. While most lesions can be treated endovascularly, there are some cases are safer with surgery. Dr. Ambekar is able to perform every procedure from the initial angiogram to the final embolization or surgery. He is also a specialist in pediatric vascular disease such as aneurysms and tumors, and treating children with surgical and endovascular techniques.
Dr. Ambekar also is specifically involved in mechanical thrombectomy for acute ischemic stroke, intracranial stenting for atherosclerotic disease, carotid endarterectomy/stenting and treatment of intracranial dural arteriovenous fistulae "
"Best Outgoing Resident in Neurosurgery (2011)
Has published over 75 peer reviewed journal articles and 5 book chapters
Research in the role of Computational Fluid Hemodynamics in characterizing the growth and rupture of intracranial aneurysms "
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