Endocrine Surgery
 
 

Thyroid

A number of thyroid disorders requires operation. Fine needle aspiration (FNA) of thyroid nodules keeps over 70% of patients  with thyroid nodules from a need for operation. Certain genetic tests can also be used to enhance non-surgical diagnosis of nodules. Despite these, operation are commonly required. Thyroid operation is considered very safe and typical stay is overnight. Complications are uncommon, but important:

  1. injury to recurrent laryngeal nerve: results in voice change and possible voice loss. Injury to one side (1% risk) is tolerated well and corrective treatment is highly effective. Injury to both sides is very uncommon, results in voice loss, and is therefore a big problem.

  2. low calcium: removal or blood flow problem with all parathyroid bodies. People usually have 4 parathyroids, each a few millimeters in size and weight 30 mg. If all are damaged or missing, permanently low blood calcium level results (2% risk); this requires high daily calcium intake and vitamin D-like medications to prevent spasms.



Parathyroid

About 1% of all people have elevated calcium due to abnormally high function of the parathyroid glands (primary hyperparathyroidism). Testing may include intact parathormone level (iPTH), calcium level, and 24 waste of calcium in urine. Imaging test are usually limited to sestamibi parathyroid scan.

Parathyroid glands are responsible for calcium handling in human body. Normally each individual has 4 glands, all located quite inconveniently behind his/her thyroid gland, hence the name. They maintain the normal calcium level in the blood by sensing current calcium level and secreting more or less of the parathyroid hormone - PTH.


Too much PTH washes calcium out of bone and calcium wasting into urine occurs. As a result blood calcium levels are usually up, leading to osteoporosis, kidney stones, pancreatitis, poor kidney function and number of other disorders. The disorder is relatively common, affecting ~1-2% of all people over age 50. Fortunately, most suffer from a mild form of disease and surgery is not necessary.


There is a quite complicated mechanism behind the parathyroid hormone function, which involves various types of calcium sensing receptors, another hormone called calcitonin, and vitamin D. Many disease states, like taking lithium or having kidney disease, affect PTH levels.


There are 3 major form of hyperparathyroidism:

1.Single gland disease (80% cases): Removal of affected gland cures patients.

2.Double gland disease (5-7% cases): Removal of affected glands cures patients.

3.4-gland disease (~10% cases): cure is not possible, but removal of 3 or 3½ gland temporarily reverses or postpones deleterious effects on the body.


Parathyroid operation is usually very well tolerated, and commonly outpatient. Complications are uncommon. Main complications include failure to find the gland (therefore patient is not cured by operation; less than 3% cases), bleeding, spasms, sore throat, and very rarely voice problem due to nerve injury.


For further information please refer to the National Institute of Health website.


Parathyroid scan localizing the abnormal gland to the right lower neck before operation:





Several abnormal parathyroids removed:







Recovering after endocrine surgery - neck

Activity: You may resume your normal daily activities upon discharge. This includes walking and climbing stairs. Avoid heavy lifting and vigorous exercise for approximately 2 weeks.

Showering: You may resume normal showering approximately 2 days after surgery. The incision does not require special care and it may get it wet. No bath/pool for 2 weeks.

Incisional: Your neck incision is closed with absorbable sutures under the skin. The is suture does not need to be removed. Small pieces of tape may be on the top of the incision. Alternatively a chemical dressing may be applied - this looks like glue and will come off by itself within 3 weeks

Pain: After surgery you may have pain at the incision, generalized neck pain or sore throat. Most patients will have discomfort 2-3 days after surgery, and the usual over the counter medications will be more effective appropriate then narcotics. Strong pain medications are usually not needed for neck pain after thyroid or parathyroid surgery.

Driving: Using judgment when to resume driving. Avoid driving if you still experiencing neck pain or use prescription pain medications. If you cannot without pain freely move the neck to the left or right as usual, you should not drive.

Return to work: Recovery after surgery depends on the individual, and the extent of surgery. Most patients are able to return to work one or 2 weeks after the surgery. Those using their voice, like teachers and call-center operator in 2-4 weeks.

Diet: There are no restrictions on diet after this type of operation.

Constipation: Anesthesia and pain medication can cause a decrease in bowel motility. If you experience constipation after the operation, you may take over-the-counter laxatives, such as milk of magnesia. We'll recommend adequate amount of fiber, usually Metamucil or Benefiber. MiraLax may be helpful as well.

Calcium supplements: We usually recommend extra strength Tums to be taken 3 times a day after surgery for approximately 4 weeks. Most patients after thyroid operation experience “stunned” parathyroid function and subsequently lower Calcium. This usually resolves within 2 or 3 weeks.

Frequently ask questions about the scar:

Most incisions swell and he takes several weeks for them to flatten down. There are no well-recognized remedies to improve the visibility of the scar. It is not known whether vitamin E. a little helps, but applying vitamin E. is not known to hurt. A gentle massage with application of vitamin E is fine.

Scar healing: The scar is closed functionally very quickly, but a process of remodeling takes up to 12 months. Most patients experience improvement in the scar of visibility with the first 2 or 3 months




Adrenal lesions, tumors & surgery


Adrenal lesions are common, and most without much risk for patients. Certain lesions may produce excess hormones.  Endocrinology of adrenal gland may be complicated, but for the basic information we consider three hormone-producing masses:

  1. aldosterone-producing tumors (aldosteronoma, Conn syndrome)

  2. cortisol-producing tumors (Cushing syndrome)

  3. epinephrin/norepinephrine-producing tumor (pheochromocytoma).


The basic workup of any adrenal lesion is to learn whether any of the above hormones are produced in excess (blood and urine tests). If production is there, operation is usually needed. If no excess production is detected, a fairly complicated decision process ensues. For most patients it results in a follow-up, not an operation.


Nearly all operations are performed laparoscopically with 3-4 small incisions and 1-2 night stay in the hospital and full recovery in 2-3 weeks. Those with pheochromocytoma require several weeks of specific medications before operation to avoid main risk of surgery for pheochromocytoma - stroke & heart failure.


Several operative pictures are shared. Right sided pheochromocytoma in a thin patient. IVC - inferior vena cava (counterpart of aorta). The pheochromocytoma is yellow/orange mass marked with yellow arrows.









A short video of right pheochromocytoma in the adrenal gland: ch1_video_02.mpg