Download Endocrine organs

Semmelweis University, Faculty of Medicine, 1st Department of Surgery
Surgery of the endocrine organs
Rezső SZLÁVIK M.D.
Endocrine organs
• hypothalamus
• hypophysis
• thyroid gland
surgery
• parathyroid glands
• suprarenal glands
• pancreatic islets
• ovary
• testicles
neurosurgery
neurosurgery
endocrine
endocrine surgery
endocrine surgery
endocrine surgery
gynecology
urology
Algorithm of thyroid-function screening
sTSH
normal
low
high
FT4, FT3
FT4, FT3
low
low
high
subclinical hypadrenia hyperlatent
hypopitu- thyr.
hyperthyr. itarismus
hypothyreosis
normal
subclinical, latent
hypothyreosis
Diagnosis of thyroid gland
•
•
•
•
•
•
•
•
•
•
•
Anamnesis, physical examination
In vitro hormone tests
X-ray (trachea, esophagus, mediastinum)
Ultrasonography (US)
Scintigraphy (SC): Tc-99, I-131
Preoperative Aspiration Biopsy, Cytology (ABC)
Antithyroid antibodies
Laryngological examination
Computer tomography (CT)
Intraoperative cytology: imprint, scraping
Intraoperative histology
Morphological approach of goiter
• Diffuse goiter
- Thyroiditis
- Graves diseaese
• Nodular goiter
-
Cysts
Autonomous nodules (adenomas)
Degenerative nodules
Tumor
Thyroid cyst
- >4 cm or >10 ml
-intracystic solids
-recurrence after puncture
surgery (?)
-remission
follow-up
Solid thyroid nodule with euthyroidism
FNAB
benign
3-12 months follow-up
thyroid US
reduction
constant
further follow-up
growth
FNAB
malignant,
benign
suspicious
LT4 suppr.
1 year
operation
thyroid US
reduction, constant
growth
Autonomous thyroid nodule
thyroid scintigraphy
hot nodule
TSH, FT4, FT3
euthyreosis
follow-up
subclinical latent
hyperthyreosis
hyperthyreosis
radioiodine th.
(exceptions)
Diffuse goiter (US)
without compression symptom
TSH, FT4, FT3
euthyreosis
under
40 years
over
40 years
200 ug iodine
for 1 year
hypothyreosis
hyperthyreosis
LT4 substit.
Basedow dissem. thyreoautonomia iditis
200 ug iodine
+LT4
after 1 year: volumetry
Treatment of Graves’ disease
• Thyreostatic treatment (drugs)
• Radiotherapy (I 131)
• Thyreidectomy (surgery)
Indications for surgical treatment
in Graves-disease
•
•
•
•
•
Relapse after drug treatment
Intolerance of antithyroid drugs
Contraindication of radioiodine therapy
Large goiter
Patient preference
Preoperative management of
hyperthyreotic patients
• Thyreostatica - 6-8 weeks
(thiamazol, propylthiouracil)
• Iodine: 5-14 days
(Plummer, Lugol, Intrajod)
• Beta-blocking drugs: propranolol etc.
• Sedative drugs
• Cardiacs
• Steroids
Types of thyroid operations
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•
•
•
•
•
•
Enucleation
Partial lobectomy
Subtotal lobectomy
Total lobectomy
Thyroidectomy (near)total
Blockdissection
Palliativ operations
Early complications of thyroid operations
•
•
•
•
•
•
•
•
•
•
Recurrent laryngeal nerve palsy
Superior laryngeal nerve palsy
Hemorrhage
Pneumothorax
Damage to thoracic duct
Damage to carotid artery
Damage to jugular vein
Thyroid crisis
Hypoparathyreosis
Infection
Malignant tumours of thyroid gland
arising from follicular
cells
differentiated
papillary
follicular
anaplastic
Primary
arising from C-cells
medullary carcinoma
non-Hodgkin malignant lymphoma
squamous-cell carcinoma – very rare
fibrosarcoma, teratoma – exceedingly rare
from lung, breast, kidney,
Secondary malignant melanoma, choriocarcinoma,
systematic malignant lymphoma
„Symptoms" of primary
hyperparathyreosis (No = 811)
Osseal:
osteoporosis, osteopenia
pathological fracture
Renal:
urolithiasis
polyuria, polydipsia
Gastrointestinal:
cholelithiasis
50
6%
258 32 %
58
7%
173 21 %
peptic ulcer
72
9%
pancreatitis
26
3%
Psychiatric:
depression
Vascular:
hypertension
„Symptom less”:
617 76 %
365 45 %
31
4%
32
4%
Preoperative localization methods of
parathyroid adenomas
 US (5 MHz head) - biopsy
 Subtraction scintigraphy (technetium-thallium,
technetium-sestamibi)
 99 Tc sestamibi scintigraphy wash-out method SPECT
 CT
 MRI
 Selective arteriography
 Selective venous sampling - PTH
 PET
 Picture-fusion combining techniques: SPECT-CT
Preoperative diagnosis of primary
hyperparathyroidism
 Laboratory proving of PHPT:
serum Ca and serum iPTH level high
 No thyroid or parathyroid operation in the
history:
only US and MIBI-scintigraphy
 Thyroid or parathyroid operation in the
history:
operation after effective localization
- MIBI, MRI and others.
Development of surgery in
primary hyperparathyroidism
 Bilateral exploration without
localization diagnostic
 Unilateral exploration after
preoperative localization
 Minimal-access operations -
with pre- and intraoperative
diagnostic procedures
Intraoperative diagnostics
during parathyroidectomy
Parathyroid localisation:
 Metilenblue staining:


intraop. i.v.
preop. under US
 Gamma-probe
Checking of the result:
 Frozen section
 Intraoperative IPTH-measurement:


in peripheral blood
in tissue aspirates
Minimal-invasive therapy of
primary hyperparathyroidism
 US- controlled alcoholic infiltration
 Selective intra-arterial injection:
absolute alcohol
alcohol + Lipiodol
 Videoscopic parathyroidectomy:
CO2 insufflation
gasless
method
cervical and/or extra-cervical ports
 Video-assisted parathyroidectomy = VAP
Adrenalectomies performed according to
hormonal activity (N=732)
Hormoninactive
43%
Conn
24%
Phaeochromocytoma
13%
Androgenoestrogen
3%
Cushing
17%
Dignity of adrenal tumours according to
diameter (N=696)
1st Surgical Dept. Semmelweis U. 1973 - 2007.
0
50
100
150
200
250
300
< 3 cm
3 - 9 cm
> 9 cm
Benign
Unsure
Malign-primary
Metastatic
350
Dignity of adrenal tumours according to
hormonal activity (N=696)
1st Surgical Dept. Semmelweis U. 1973 – 2007.
Number
of cases
0
50
100 150 200 250 300 350
Cushing
Conn
Androgen
Oestrogen
Phaeochromocytoma
Hormoninactive
Benign
Unsure
Malign
Techniques of adrenalectomy
Traditional
retroperitoneal
transabdominal
Videoscopic
laparoscopic (1992 - )
retroperitoneoscopic (1994 - )
Contraindications of laparoscopic
adrenalectomy
 large tumor: > 6-9 cm
 locally invasive malignoma
 general contraindications of
laparoscopic operations
GEP – neuroendocrine tumors
Cell Hormone
Tumour
A
B
D
F
G
glucagon
insulin
somatostatin
pancreas polypeptid
gastrin
?
vasoactiv intestinal polypeptid
EC
serotonin
glucagonoma
insulinoma
somatostatinoma
PP-oma
gastrinoma
(ZE syndr.)
VIP-oma
(WDHA syndr.)
carcinoid
Leading symptoms of hyperinsulinism
Hypoglycemic symptoms
without collapse
Collapse
Collapse with convulsion
Symptoms persisted : 3,5 years (mean)
( 2 months - 24 years )
Localization methods of
insulomas
Ultrasonography (endoscopic too)
CT, angio-CT
MRI
Scintigraphy (octreotid)
Selective arteriography, SAST
Selective venous sampling
Intraoperative US
Results of diagnostic procedures in patients
with insuloma verified by operation
No of cases:15
34
62
47
29
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Fals
Partially
True
i
c
S
.
nt
Ar
ri
e
t
.
r
og
US
CT
US
.
p
o
ra
t
In