Endocrine Surgery

STAFF

Dr. Brian Hung Hin LANG
(Division Chief)

• Dr. Brian Hung Hin LANG
  Division Chief
  MBBS (Hons), MS (HK), MRCS (Edin.), FRACS, FCSHK, FHKAM
  e-mail: blang@hku.hk

• Dr. Kai-Pun WONG
  Resident
  MBBS, MRCS(Edin)

• Dr. Yuen-Ki FONG
  Resident
  MBBS, MRCS(Edin)

• Dr. Kin-Yee HUNG
  Resident
  MBBS, MBChB

• Miss Wai-Pui CHU
  Research Assistant
  

SCOPE AND SERVICE

The Division of Endocrine Surgery is dedicated to the clinical service and research of endocrine surgical diseases in collaboration with endocrinologists, radiation oncologists, radiologists and endocrine pathologists. A stand-alone service with separate beds, one full-time staff and three surgical residents aims at providing a high standard of care to patients in the following endocrine diseases:

• Thyroid
• Parathyroid
• Adrenal
• Pancreatic endocrine disease

Thyroid diseases and thyroid cancer

More than 800 new patients with various thyroid diseases are seen and 250-300 thyroid operations are performed each year. Uninodular and multinodular goitre are common problems prevailing in our population. Fine needle aspiration cytology is frequently performed under ultrasound guidance. Thyroidectomy is performed for thyroid malignancy in about 20 % of patients. Surgery for retrosternal goitre and thyroid re-operations account for 14 and 16% of patients undergoing thyroid surgery respectively. Surgical treatment for thyrotoxicosis will be performed in selected patients. Our incidence of permanent hypoparathyroidism and vocal cord palsy is 1.6% and 0.9% respectively.

Thyroid cancer is the most common endocrine malignancy. All patients with thyroid carcinoma are managed by a standard protocol with Department of Clinical Oncology. This includes adjuvant radioactive iodine treatment and whole body scan + external beam irradiation for high-risk patients. Patients are closely followed in the Combined Thyroid Clinic jointly with the radiation oncologist.

   Papillary thyroid carcinoma

   "Scarless in the neck" thyroidectomy

   Endoscopic thyroidectomy

   Robotic assisted thyroidectomy

Parathyroid diseases

Primary hyperparathyroidism

Hypercalcemia due to primary hyperparathyroidism is increasingly diagnosed and referred for surgical treatment. The number of cases of primary hyperparathyroidism diagnosed and referred for surgical treatment (Figure) has increased dramatically, especially over the last 10 years.  Surgical treatment has been successful in 98% of patients with or without preoperative localization. Reoperations for failed initial cervical exploration elsewhere accounts for 4% of patients surgically treated. Preoperative technetium sestamibi scanning and ultrasonography are performed to select patient for minimally invasive parathyroidectomy.  Endoscopic assisted and focused was performed parathyroidectomy with intraoperative parathyroid hormone assay is performed for majority patients under cervical block or local anaesthesia.

Preoperative technetium sestamibi scan

Endoscopic assisted parathyroidectomy

  Intraoperative PTH assay

6 weeks after endoscopic parathyroidectomy

Secondary or tertiary hyperparathyroidism

Surgery for secondary and tertiary HPT is performed for patients referred from renal physicians and is indicated in 15-20% of patients with renal failure who develop biochemical, radiological features or symptomatology related to hyperparathyroidism. Total parathyroidectomy with immediate autotransplantation of parathyroid gland to forearm is the procedure of choice.

Parathyroid cryopreservation

Routine cryopreservation of parathyroid tissue is performed for patients during parathyroid re-operations or for those who undergo surgery for with secondary or tertiary hyperparathyroidism. The tissue is stored in our parathyroid tissue bank for delayed autotransplantation if patients develop permanent hypocalcaemia.

Adrenal diseases

Adrenalectomy for various adrenal diseases is performed for patients referred from our endocrinologists. Hormonal evaluations for various adrenal diseases including primary hyperaldosteronism, Cushing syndrome and pheochromocytoma areas are performed jointly with endocrinologists. Preoperative localization tool including CT scan, MRI and radio-isotope scanning such as NP59 scan and MIBG scan are available. Percutaneous adrenal venous sampling is performed whenever indicated by a team of experienced interventional radiologists with the support of experts from Department of Biochemistry. Incidentally discovered adrenal masses are investigated according to a standard protocol. Functioning or suspicious malignant tumours will be subjected to surgical treatment.

Laparoscopic adrenalectomy

Adrenalectomy through laparoscopy is a new standard of treatment for the majority of patients requiring adrenalectomy. More than 70% of our patients have been operated through this approach with a success rate of 93%. Patients who undergo adrenalectomy through approach have a shorter hospital stay, less wound pain, less analgesic requirement and a more rapid postoperative recovery compared with open approaches.

Laparoscopic right adrenalectomy

(Right aldosteronoma)

1 week after bilateral adrenalectomy

(Cushing syndrome)

Pancreatic endocrine disease

Insulinoma is the most common pancreatic endocrine disease. Preoperative localization studies including CT scan, MRI, endoscopic ultrasound and octreotide scanning are available. Intra-arterial calcium injection with hepatic venous sampling is performed by experienced Radiologists from Department of Radiology with high success rate. For patients with negative localization, a combination of intraoperative localization by palpation and intraoperative ultrasound has achieved a high success rate in surgical treatment of patients with hyperinsulinemia. Minimal invasive surgery by laparoscopic enucleation and distal resection has been performed with success in selected patients. 

Laparoscopic ultrasonography before resection

CURRENT RESEARCH AREAS (Clinical and laboratory)

• Clinicopathologic studies of thyroid carcinoma
• Cycloxygenase in thyroid carcinoma
• VEGF-C, p16, CDK4 and TGFa in thyroid cancer
• Ret-PTC oncogene expression in papillary thyroid carcinoma
• Somatic polymorphism in thyroid cancer
• Arterial stimulated venous sampling for preoperative localization of pancreatic insulinomas
• Sequential chemotherapy combined with hepatic artery embolization for metastatic insulinomas
• Multiple endocrine neoplasia in Chinese : clinicopathologic and genetic study
• Preoperative localization using ultrasonography and sestamibi scanning for primary hyperparathyroidism