1. 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

2. Endocrine surgery Parathyroid - hyper and hypo parathyroidism Adrenal tumors - cushing syndrome - conn`s disease - pheochromocytomas - adrenocortical carcinoma - incidentilenoma Pancreatic endocrine tumors Carcinoid tumors

3. Parathyroid Superior parathy. 4 th branchial pouch Inferior 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 ).

4. Hyper parathyrodism Primary : 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

5. Hyper parathyroidism Tertiary : - 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

6. Hypo parathyroidism Secondary to thyroidictomy 90% dut to ischemia to the gland 10% accidental removal of the gland Signs and symptoms Treatment asymptomatic, mild symptoms, sever symptoms

7. Adrenal gland 80% cortex - zona glomerulosa…..aldosteron (mineralocorticoid) - zona fasciculata, reticularis ….cortison, androgen (glucocorticoid) under ACTH control 20% medulla - adrenalin, noradrenalin

8. Normal Anatomy, Abdominal-pelvic CT Liver Spleen Inferior vena cava aorta Stomach Vertebra Ribs Vertebra Left kidney Right kidney Left portal vein Left adrenal

9. Cushing syndrome Defenition 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.

10. Cushing syndrome Diagnosis : - 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 ).

11. 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 )

12. Pheochromocytomas Adrenal medulla 10% 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

13. 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…

14. Carcinoid tumor Arise from neural crest cells. Site : - GIT : any site, most common is appendix, ileum, rectum. - extraintestinal : bronchus and ovary. Prognosis depend on the size ; 2 cm 80% L.N metastasis. Lead to extensive fibrosis, fixation and kinking of the bowel.

15. Carcinoid tumor Can 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

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

17. Gastrinoma Zollinger-Ellison syndrom. Increase secretion of gastrin. recuurant peptic ulcer and diarrhea. Could associated with MEN I.

18. Glucagon-secreting tumor Diabets Anemia Weight loss DVT Cutaneous lesion ( necrolytic migratory erythema)