Endocrine surgery

Dr. Saleh M. Aldaqal MBBS, FRCSI,SBGS

Assistant Professor and Consultant General And laparoscopic

Surgery(france), Department of Surgery, Faculty of

Medicine, King Abdulaziz University.www.dr-aldaqal.com

Endocrine surgeryParathyroid - hyper and hypo parathyroidismAdrenal tumors - cushing syndrome - conn`s disease - pheochromocytomas - adrenocortical carcinoma - incidentilenomaPancreatic endocrine tumorsCarcinoid tumors

ParathyroidSuperior parathy. 4 th branchial pouchInferior parathy. 3 rd branchial pouch (

50% ectopic)90% 4 glands, 10% 5-6 glands.Both receive blood supply from inferior

thyroid artery.Direct feedback by Ca level, no pituitaty

control.PTH has direct effect on bone ( osteoclast)

and kidneys ( tubular reabsorption) and indirect effect on the GIT ( renal vitam. D ).

Hyper parathyrodismPrimary : due to disease in the gland as adenoma

(80%), hyperplasia ( 15%), carcinoma (5%) ( high ca. and PTH ) treatment : surgery

Secondary : compensatory response to hypoca. - CRF ( hyperphosphatemia, reduction in vitam. D ) - intestinal malabsorption syndrom ( ca. level at lower normal, high PTH ) treatment : calcium, vitam. D, phosphate binder Indication of surgery : sever renal osteodystrophy

Hyper parathyroidismTertiary : - long standing secondary

hyperparathyroidism lead to autonomous hyperfuncion of the gland.

- high PTH, high normal to elevated ca. level. - 10% required surgery. - indication of surgery : - persistant hyperca. And elevated PTH

with normal renal function -extensive soft tissue calcification with tumoral calcinosis -calciphylaxis

Hypo parathyroidism Secondary to thyroidictomy90% dut to ischemia to the gland10% accidental removal of the glandSigns and symptomsTreatment asymptomatic, mild symptoms, sever

symptoms

Adrenal gland80% cortex - zona glomerulosa…..aldosteron

(mineralocorticoid) - zona fasciculata, reticularis ….cortison,

androgen (glucocorticoid) under ACTH control

20% medulla - adrenalin, noradrenalin

Normal Anatomy, Abdominal-pelvic CT

Liver Spleen

Inferior vena cava

aorta

Stomach

Vertebra

Ribs

Vertebra

Left kidney

Right kidney

Left portal vein

Left adrenal

Cushing syndromeDefenition Causes : - 90% iatroginc exogenous - 10% endogenous ( 70% pituitary adenoma, 29% adrenal

causes, 1% ectopic production due to carcinoma as ca. lung)

Adrenal causes : most commonly due to adenoma, followed by

carcinoma and rarly due to hyperpasia.

Cushing syndromeDiagnosis : - 24 h urinary free cortisol - to confirm the diagnosis , low dose

dexamethasone suppression test. - then ACTH level, if low, adrenal causes - if ACTH level high, then high dose

dexamethasone suppression test ( pituitary or ectopic ).

Conn`s disease ( primary hyperaldosteronism)

Aldosteron secretion is under control of renin-angiotensin system, serum potassium.

Sustained hypertension , Hypokalemia.

95% adrenal adenoma ( surgical)

5% adrenal hyperplasia (medical )

Pheochromocytomas Adrenal medulla10% tumor - 10% bilateral - 10% malignant - 10% extra adrenal ( paraganglia cells in

abdomen, carotid body, urinary bladder) - younger than 20 years of age - 10% MEN II

Pheochromocytomas Symptoms : headache, paroxysmal hypertensive

episode, palpitations, sweating..)Diagnosis - 24 h urinary catecholamines and metabolites ( metanephrines, VMA ) - CT- scan - MIBG isotop scan ( monoiodobenzylguanidine )Treatment : surgical - pre operative preparation with alph-

blocker as phenoxybenzamine , fluid…

Carcinoid tumorArise from neural crest cells.Site : - GIT : any site, most common is appendix,

ileum, rectum. - extraintestinal : bronchus and ovary.Prognosis depend on the size ; < 1 cm 20-

30% L.N metastasis. > 2 cm 80% L.N metastasis.

Lead to extensive fibrosis, fixation and kinking of the bowel.

Carcinoid tumorCan lead to carcinoid syndrome. - flushing, diarrhea, asthma, valvular heart

disease. - secret serotonin. - diagnosis : 24h urinary 5-HIAA - developed when there is extensive liver

metastasis, or extra intestinal tumor. - treatment : surgery, somatostatin

Pancreatic endocrine tumorInsulinomaWhipple`s triad - symtoms of fasting hypoglcemia. - fasting hypoglycemia < 50 mg/dl. - relieved by glucose administration.Single, benign tumor.Treatment : surgical

Gastrinoma Zollinger-Ellison syndrom.

Increase secretion of gastrin.

recuurant peptic ulcer and diarrhea.

Could associated with MEN I.

Glucagon-secreting tumor

DiabetsAnemiaWeight lossDVTCutaneous lesion ( necrolytic migratory

erythema)

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