We present an interesting scenario of dual pathology found within the thyrothymic tract of a patient with primary hyperparathyroidism. Pre-operatively, Tc-99 m sestamibi and 4-D parathyroid CT were concordant for a solitary adenoma adjacent to the lower pole of the right thyroid lobe. CT also reported an indeterminate 'vascular lesion' adjacent to the adenoma. At surgery, a 690 mg fat deplete parathyroid adenoma was identified at the cranial end of the thyrothymic tract (Fig. 1). Macroscopically, an incidental second lesion was noted. This appeared as a well-defined 8 mm ovoid pinkish lesion with a feeding vessel from the inferior thyroid artery. This was larger than a normal parathyroid gland but smaller than expected for a second adenoma. Colouration was not typical of either a normal parathyroid ('London tan') or an adenomatous/hyperplastic one ('brick red'). Sharp edges and a 'feeding vessel' are shared attributes of parathyroid glands. Histology reported a thymic hamartoma composed of mature fat, malformed vessels, and thymic elements—a 'thymoangiolipoma' (Fig. 2). Thymic neoplasms are rare tumours that account for less than 1% of all adult malignancies.1 There are only two prior reports of a thymoangiolipoma in the literature. We present this finding to raise awareness amongst surgeons of thymic lesions to avoid misidentification and potentially non-curative parathyroid surgery. Whilst the risk of this occurring is low with the benefit of positive pre-operative localizing studies, it is possible in cases of non-localisation or multi-gland hyperplasia where 4 gland (bilateral neck) exploration is required. The thymus is a specialized lymphoid organ found in the anterior mediastinum that plays an important role in the development of the cellular immune system.2, 3 The thymus and inferior parathyroid glands share an embryological origin from the third pharyngeal pouch. Both disconnect from the pharyngeal wall and descend; the thymus to the mediastinum and the inferior parathyroids coming to rest in a more cranial location posterior to the thyroid.4 Up to 16% of parathyroid glands are ectopic and found along the path of embryological descent.5 Thymic tumours may be of epithelial or non-epithelial cell origin.6 First described by Hall in 1949,7 thymoangiolipomas are a rare subtype of epithelial derived thymolipomas. Diagnosis is histological, and it is thought that the lesions are either hamartomas or neoplastic lesions arising from thymic fat.8-10 To our knowledge this is the third ever reported case of a thymoangiolipoma; the first reported in Australia and during parathyroidectomy. Focal thymic lesions can mimic enlarged parathyroid glands and this should be kept in mind when evaluating inferior glands. In cases where abnormal parathyroids are localized on pre-operative imaging and these are correlated with macroscopic operative findings, the risk of mis-identification is low. When localizing studies are discordant or negative (multi gland hyperplasia) and bilateral neck exploration is undertaken, lesions that do not meet all the criteria of a pathological parathyroid gland should be viewed with a degree of caution. Adjuncts to aid in the correct diagnosis macroscopically include size around 10 mm, bean shape, brick red colour, sharp edges and a polar vessel. Thymic lesions, thyroid rests and lymph nodes tend towards shades of pink. Where doubt persists, confirmation can be sought by frozen section analysis or intra-operative PTH level. Open access publishing facilitated by The University of Notre Dame Australia, as part of the Wiley - The University of Notre Dame Australia agreement via the Council of Australian University Librarians. Samuel Thompson: Investigation; resources; visualization; writing – original draft. Elan Novis: Project administration; writing – original draft; writing – review and editing. Julia Low: Investigation; resources; writing – review and editing. Tamara Preda: Conceptualization; resources; supervision; validation; writing – review and editing. Patient consent was obtained for presentation of this clinical case. Institutional ethics approval not required due to single case presentation.

Background: Near-peer teaching (NPT) involves teaching by peers who are at a close, but not the same, level of training. This study investigated whether a novel surgical NPT workshop, designed and delivered by junior doctors using simulation models for acute otolaryngology conditions, improved the knowledge and confidence level of senior medical students. Methods: A one-day NPT workshop was held for medical students in their third year of a four-year postgraduate medical degree at the University of Notre Dame, Sydney, Australia. Four acute otolaryngology/head and neck surgery problems that might be encountered by junior doctors and require prompt management were chosen. These were post-operative neck swelling, epistaxis, and tracheostomy management (obstruction and bleeding). Six junior doctors facilitated didactic tutorials and practical skills training using models. Multiple choice question mini-tests and questionnaires were administered before and after the workshop to assess changes in students' knowledge and confidence in assessment, management, and practical skills. Results: The most common reason for participation was to acquire knowledge and practical skills (93.2 %). Mean correct MCQ mini-test knowledge scores increased significantly from 60 % pre-workshop to 83.9 % post-workshop (p < 0.05). Students reported significantly increased confidence in recognition and management of all four conditions. All students favoured including the course in their curriculum and would recommend the course to others. The tutors subjectively reported valuable teaching experience. Conclusion: NPT is an effective method for teaching medical students how to assess and manage acute otolaryngology/ENT surgery conditions that may present as emergencies for junior medical officers on the ward.

Received: September 10, 2022. Revised: November 16, 2022. Accepted: December 05, 2022 © The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Dear Editor

This study investigated whether there was a change in acute appendicitis, appendicectomy admissions or disease severity during the 2020 lockdown period in NSW.

Chronic kidney disease has an estimated prevalence of 10% in Australia and is predicted to rise in the coming years. Secondary hyperparathyroidism resulting from chronic kidney disease is an important cause of morbidity in these patients; and screening for secondary hyperparathyroidism is recommended in international guidelines. We present the case of a chronic kidney disease patient who developed recurrent hyperparathyroidism despite previous "total" parathyroidectomy and subsequent renal transplant. After targeted investigations he was diagnosed with an accessory parathyroid gland in his thorax, causing the recurrent hyperparathyroidism. He was managed with a thoracoscopic excision with a resultant drop in parathyroid hormone consistent with surgical cure. This case highlights the rare phenomenon of supernumerary and ectopic parathyroid glands. Cross sectional thoracic imaging can and should be used to detect and localize supernumerary glands not apparent at the time of original surgery.

Background The primary objective was evaluation of axillary ultrasound (AxUS) in preoperative staging of patients with invasive carcinoma undergoing breast-conserving surgery. Methods This is a retrospective, observational cohort study of patients with clinically node-negative (cN0) biopsy-proven invasive breast carcinoma undergoing breast-conserving surgery between January 2011 and December 2014 who underwent AxUS with fine needle aspiration (FNA) biopsy of sonographically abnormal lymph nodes. Patient records were reviewed. Results A total of 713 cases were analysed. Four hundred and thirty-three patients underwent formal preoperative AxUS; 100 underwent biopsy for abnormal findings. Of these, 32 had positive FNA biopsy result and underwent level II axillary dissection (axillary lymph node dissection (ALND)). Thirty were T1-2 tumours with AxUS scan/FNA demonstrating sensitivity of 25.2%, specificity of 100%, positive predictive value of 100% and negative predictive value of 76.6%. Forty-six patients had a positive sentinel lymph node (SLN) biopsy and axillary dissection. 34.8% of T1 tumours, 47.8% of T2 tumours and 100% of T3 tumours had further positive nodes. The average number of nodes involved per axilla was 1.8 for the T1 group, 4.1 for the T2 group and 4.6 in the T3 group. Macrometastases were a more common finding than micrometastases for all T stages undergoing ALND. A suspicious preoperative AxUS result was significantly associated with positive SLN. Other risk factors for positive SLN biopsy were oestrogen receptor positivity and lymphovascular invasion. Conclusion AxUS identifies patients with high nodal burdens justifying immediate ALND. AxUS did not adversely affect women with histologically negative sentinel nodes. Three percent may have been overtreated.

ANZ Journal of SurgeryVolume 90, Issue 7-8 p. 1519-1520 IMAGES FOR SURGEONS Inflammatory myofibroblastic tumour presenting with the acute abdomen: an uncommon cause of a mesenteric mass Michael J. Papanikolas B. Med, Michael J. Papanikolas B. Med orcid.org/0000-0003-4450-4983 Department of Surgery, Liverpool Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorMichelle Z. Chen MBBS, MS (Colorectal), Michelle Z. Chen MBBS, MS (Colorectal) Department of Surgery, Liverpool Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorTamara C. Preda BSc (Med), MBBS, FRACS, MMed/Surg, Tamara C. Preda BSc (Med), MBBS, FRACS, MMed/Surg orcid.org/0000-0002-5379-1980 Department of Surgery, Liverpool Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this author Michael J. Papanikolas B. Med, Michael J. Papanikolas B. Med orcid.org/0000-0003-4450-4983 Department of Surgery, Liverpool Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorMichelle Z. Chen MBBS, MS (Colorectal), Michelle Z. Chen MBBS, MS (Colorectal) Department of Surgery, Liverpool Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorTamara C. Preda BSc (Med), MBBS, FRACS, MMed/Surg, Tamara C. Preda BSc (Med), MBBS, FRACS, MMed/Surg orcid.org/0000-0002-5379-1980 Department of Surgery, Liverpool Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 27 December 2019 https://doi.org/10.1111/ans.15617Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume90, Issue7-8July/August 2020Pages 1519-1520 RelatedInformation

Alterations in gastrointestinal, pancreatic, and adipose hormone levels may have a greater role in weight loss than initially appreciated. The laparoscopic sleeve gastrectomy (LSG) operation is now the most frequently performed bariatric operation in many countries, but there are relatively few data regarding its molecular effects. We sought to characterize the effect of LSG on fasting plasma levels of selected hormones and on non-esterified fatty acids (NEFA), and to compare these to levels in non-obese control individuals.

The closure of a circular defect resulting from excision of large soft-tissue tumours may pose a considerable surgical challenge. We have described a successful result from the use of modified double helix rotation flaps following resection of a fungating 15-cm interscapular basal cell carcinoma. Our technique necessitated a single operation only. Alternatives considered were split skin grafting, Keystone flap repair or a myocutaneous flap. All modes of repair carry the risk of tension with resultant necrosis and infection. In our case, wound infection did occur, largely due to a heavy pre-operative microbiological burden. This was treated with intra- and postoperative antibiotics and there was no need for subsequent debridement. We propose the double helix flaps as an alternate means to successful local closure of large circular soft-tissue defects.

ANZ Journal of SurgeryVolume 78, Issue 8 p. 709-710 SCLEROSING MESENTERITIS PRESENTING WITH ABDOMINAL PAIN AND FEVER IN A YOUNG WOMAN: COMPUTED TOMOGRAPHY FINDINGS Martine Preda BSc, MB BS, Martine Preda BSc, MB BS Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorCraig Buchan MB BS (Hons), B Comm, Craig Buchan MB BS (Hons), B Comm Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorTamara Preda BSc, MB BS, Tamara Preda BSc, MB BS Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorPraneal Sharma MB BS, FRANZCR, Praneal Sharma MB BS, FRANZCR Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this author Martine Preda BSc, MB BS, Martine Preda BSc, MB BS Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorCraig Buchan MB BS (Hons), B Comm, Craig Buchan MB BS (Hons), B Comm Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorTamara Preda BSc, MB BS, Tamara Preda BSc, MB BS Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorPraneal Sharma MB BS, FRANZCR, Praneal Sharma MB BS, FRANZCR Department of * Radiology and ‡ Surgery, Liverpool Hospital, and † Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 10 August 2008 https://doi.org/10.1111/j.1445-2197.2008.04623.xCitations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume78, Issue8August 2008Pages 709-710 RelatedInformation