Endocrine Surgery
Endocrine Surgery rewards a systematic approach: confirm the biochemical diagnosis, localise the lesion, then choose the operation and anticipate its specific complications.
Thyroid
- Investigate a nodule with TSH, ultrasound and fine-needle aspiration reported by the Bethesda system; Bethesda IV-VI usually needs surgery.
- Total thyroidectomy risks: haematoma causing airway compromise (reopen the wound at the bedside), recurrent laryngeal nerve injury (unilateral hoarseness, bilateral stridor) and hypocalcaemia from parathyroid devascularisation - check calcium on day 1.
- Medullary carcinoma: measure calcitonin, test for the RET proto-oncogene, and screen for phaeochromocytoma and hyperparathyroidism (MEN 2).
Parathyroid
Primary hyperparathyroidism is hypercalcaemia with inappropriately raised or non-suppressed PTH, usually a single adenoma (80-85%). Localise with ultrasound and sestamibi; confirm cure with intraoperative PTH falling more than 50% from the pre-excision value 10 minutes after removal.
Adrenal
Phaeochromocytoma: never beta-block first. Alpha blockade with phenoxybenzamine for 10-14 days prevents intraoperative hypertensive crisis. Conn's syndrome (hypertension, hypokalaemia, suppressed renin) and Cushing's syndrome (adrenal adenoma versus pituitary ACTH excess) follow the same confirm-localise-resect logic.
Endocrine pancreas and breast
- Insulinoma: Whipple's triad, fasting hypoglycaemia with high insulin and C-peptide.
- Gastrinoma: refractory ulcers, high gastrin, positive secretin stimulation test.
- Breast: triple assessment (clinical, imaging, core biopsy) with ER, PR and HER2 status determining adjuvant therapy; sentinel node biopsy for clinically node-negative invasive disease.
Worked example
A 34-year-old woman with renal stones has calcium 2.95 mmol/L, PTH 120 ng/L and raised 24-hour urinary calcium. That is primary hyperparathyroidism; sestamibi localises a left inferior adenoma, and focused parathyroidectomy is confirmed by a fall in PTH of more than 50% at 10 minutes.
Traps
Giving propranolol first in phaeochromocytoma; forgetting to exclude phaeochromocytoma before operating for medullary thyroid cancer; missing a post-thyroidectomy haematoma because the drain looks dry.