dr. saleh m. aldaqal mbbs, frcsi,sbgs assistant professor and consultant general and laparoscopic...
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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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