The 1996 consensus statement on thyroid disease by the Royal College of Physicians of London and Society of Endocrinology ¹⁴ stated: ‘each District General Hospital should have access to an experienced thyroid surgeon’. Although surgery of the endocrine glands is currently the scene of dispute between general surgeons (endocrine/upper gastrointestinal/hepatobiliary), head and neck, oromaxillofacial, ENT surgeons and urologists, no individual group has an unassailable right to care for and treat the patients. The needs of the patient must come first. The introduction to the British Association of Endocrine and Thyroid Surgeons (BAETS) guidelines¹⁵ states:

“[the guidelines do] not define an endocrine surgeon or specify who should practice endocrine surgery … Elective endocrine surgery will not be in the portfolio of every District General Hospital, but where it is, based on experience and caseload, it should be in the hands of a nominated surgeon with an endocrine interest. Those patients requiring more complex investigation and care as detailed in the guidelines should be referred to an appropriate centre. These rare and complex diseases will only be managed effectively by multidisciplinary teams in Units familiar with these disorders … this category includes patients with endocrine pancreatic tumours, adrenal tumours, thyroid malignancy especially medullary thyroid carcinoma, familial syndromes and those requiring reoperative thyroid and parathyroid surgery.”

The advantages of subspecialisation

It is all too easy to lose sight of the important issues:

1. The surgeon should have been appropriately trained.

In the UK, the higher surgical trainee who declares an interest in endocrine surgery should spend at least 1 year in an approved unit, which should consist of:

• one or more surgeons with a declared interest in endocrine surgery;

• an annual operative workload in excess of 50 cases (verified by BAETS audit);

• on-site cytology and histopathology services;

• at least one consultant endocrinologist on site, holding one or more dedicated endocrinology clinics per week, with joint clinics or formal meetings held not less than once per month;

• a Department of Nuclear Medicine on site;

• on-site magnetic resonance imaging (MRI) and computed tomography (CT) scanning.

In practical terms flexible rotations between regions may be required for more specialised areas of endocrine practice, such as adrenal surgery.

The current syllabus (www.iscp.ac.uk/documents/syllabus_GS_2010.pdf) and subspecialist curriculum (www.baes.info/Pages/BAETS%20Guidelines.pdf) for endocrine surgical training in the UK are well defined. Examples of how endocrine surgical operative experience and competence for an individual trainee can be identified and rated (www.nthst.org.uk/Assets/Files/RITA_forms/NTHST_OpComp_Endocrine_v_1.doc) are available, and in future will help define what constitutes ‘appropriately trained’.

2. The surgeon must be part of an experienced multidisciplinary team.

Complication rates following thyroid, parathyroid and adrenal procedures are higher in patients treated by non-specialists, and lower when ‘high-volume’ surgeons operate or patients are treated in high-volume centres.16–20 This is also true for paediatric endocrine surgery.^21,²² Supervised trainees and newly established endocrine surgeons can perform thyroid surgery safely.^23–25

The care of patients with thyroid cancer should be the responsibility of a specialist multidisciplinary team (MDT) that comprises surgeon(s), endocrinologist and oncologist (or nuclear medicine physician) with support from pathologist, medical physicist, biochemist, radiologist and clinical nurse specialist. All should have expertise and interest in the management of thyroid cancers and show commitment to continuing education in the field.

There is evidence from the UK and the USA to support a continued need for subspecialisation in endocrine surgery and adherence to good practice, e.g. total thyroidectomy and lymph node dissection is the standard of care in patients with medullary thyroid cancer (MTC) yet 10–15% of patients with MTC undergo less than total thyroidectomy and 30–40% of patients have no cervical node dissection.26–29 MTC is rare; all patients should be referred for surgical treatment to a cancer centre.

3. As the quality of the care received by the patient is paramount it should be subject to assessment by audit and benchmarking against agreed standards.

In 1998, a retrospective study from a single district hospital identified that only 42% of patients with thyroid cancer presenting with a thyroid nodule had preoperative fine-needle aspiration cytology (FNAC).³⁰ In contrast, BAETS audit data from 2009 reported that 82% of treated patients, confirmed at histology to have a neoplastic lesion, underwent fine-needle aspiration (FNA) prior to the operation.²⁹ The collection of such prospective information on endocrine surgical activity in the UK is crucial, not only for issues of surgical subspecialisation but for education and training. For UK surgeons, continuing full membership of the BAETS is conditional upon the submission of their clinical activity to the audit. It is likely in the future that General Medical Council (GMC) revalidation will require confirmation that surgeons take part in comparative national audit. The following standards and outcome measures are suggested as being applicable to current endocrine surgical practice.