Endocrine Surgery


    • Dx: Patients present with hypergastrinemia and severe recurrent peptic ulcer disease (Zollinger Ellison syndrome)
      • Rule out MEN I (parathyroid, pancrease, and pituitary tumors).
      • Fasting gastrin > 1000pg/ml
      • Secretin stimulation test confirms (gastrin increases with gastrinoma).
      • Localization is done with CT, octreotide scan, endoscopic US, IOUS, or duodenoscopy.
      • Gastrinoma triangle= cystic duct-common duct junction, 2nd/3rd duodenum, neck/body of pancreas
    • Tx: Management depends on localization (gastrinoma triangle is junction of cystic duct, the common bile duct, and D2/D3 junction inferiorly)
      • Duodenum gets enucleation (consider whipple if unable to enucleate)
      • Metastasis to liver gets debulking, PPI, somatostatin, and streptozotocin.
      • Non-localization gets duodenotomy, IOUS, consider acid reducing operation, and somatostatin.


    • Dx: Patients present with Whipple's triad (hypoglycemia symptoms, hypoglycemia, and relief of symptoms with glucose).
      • Elevated insulin, low glucose, elevated C-terminal peptide.
      • Rule out MEN I
      • Differential of hypoglycemia includes cirrhosis, glycogen storage disease, large tumors.
      • Localization is done with CT ab/pelvis, endoscopic US, octreotide scan, arteriogram, or IOUS.
    • Tx: Start with diazoxide or somatostatin until surgery.
      • Surgical treatment is enucleation
      • If unable to localize, can do distal pancreatectomy and frozen section.
      • MEN I should have subtotal pancreatectomy


    • Sx: DM, necrolytic migratory erythema, DVT
    • Dx
      • serum glucagon > 500pg/ml
      • usually located in head/tail of pancreas
      • often have mets
    • Tx: surgical resection and debulking


    • vasoactive intestinal paptide secretion
    • Sx: watery diarrhea, hypokalemia, achlorhydria (WDHA syndrome)
    • Dx:
      • usually tail of pancreas
      • often have mets
    • Tx: surgical resection


    • Sx: inhibited pancreatic/biliary secretion giving cholelithiasis, DM, steatorrhea
    • Dx: serum somatostatin > 10ng/ml; (often metastatic)
    • Tx: resection, cholecystectomy

Adrenal Incidentaloma

    • Dx: These are discovered incidentally on CT scan for other reasons
      • Determine size and hounsfield units for likelyhood of malignancy.
        • Adenoma is <4cm, <10 hounsfield, and fatty. Contrast washout > 60%
        • Carcinoma is >4cm, have necrosis, calcifications, and hemorrhage.
      • Start with biochemical evaluation:
        • 24hr urine cortisol
        • 24hr urine metanephrine, normetanephrine
        • Aldosterone/renin if HTN and hypokalemic (Abnormal ratio is > 20)
    • Tx: Managment depends on size and activity.
      • Biochemical activity requires resection
      • Carcinoma featurs on CT require resection.
      • adenoma < 4cm can watch
      • adenoma > 4cm needs excision
      • Laparoscopic adrenalectomy can be used for tumor < 6cm.
      • Anterior Adrenalectomy:
        • Laparotomy and survey abdomen.
        • Left side= take down splenic flexure
        • Right side= take down hepatic flexure, kocherize the duodenum, take down right triangular ligament.
        • Enter gerota's fascia, start cephalad, and dissect towards renal hilum.
        • Dissect between adrenal and pancreas/spleen (left) or liver (right).
        • Identify adrenal vein and ligate (left side renal vein, right side off posterior surface of IVC).
        • Continue dissection over renal capsule.
        • Remove retroperitoneal fat with the adrenal gland.