Clinical Challenges in Endocrine Surgery: Adrenalectomy Guidelines Review

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Mar 23, 2023

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ADVICE

Rule Out Pheo By Low Non-Contrast HU

If a CT non-contrast Hounsfield unit (HU) is <10, you can practically rule out pheochromocytoma by imaging alone.
Proceeding with urgent non-adrenal surgery is reasonable after confirming low non-contrast HU, but discuss anesthesiology concerns first.

ANECDOTE

Anesthesia Opted For Full Biochemical Workup

An anesthesiology team felt uncomfortable proceeding without biochemical testing despite low HU imaging, so the colorectal case was canceled.
The operation was later done after full biochemical workup and the patient did well.

ADVICE

Systematic Hormone Workup For Incidentalomas

Systematically test adrenal incidentalomas for aldosterone, cortisol, and catecholamine excess when indicated.
Start with aldosterone/renin ratio for hypertensive patients and use DST or DHEAS/ACTH for cortisol evaluation.

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In this episode the Endocrine Surgery team at BTK goes over two cases to review the American Association of Endocrine Surgeons Guidelines for Adrenalectomy.

Dr. Michael Yeh is a Professor of Surgery at UCLA and serves as Section Chief of the UCLA Endocrine Surgery program which he established.

Dr. Masha Livhits is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department

Dr. James Wu is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department

Dr. Na Eun Kim is an Endocrine Surgery Fellow at UCLA in his first year of fellowship

Dr. Rivfka Shenoy is a PGY-5 General Surgery Resident at UCLA who has completed two years of research

Dr. Max Schumm is a PGY-5 General Surgery Resident at UCLA who has completed two years of research. He is a future endocrine surgeon.

Important Papers

Yip L, Duh QY, Wachtel H, Jimenez C, Sturgeon C, Lee C, Velázquez-Fernández D, Berber E, Hammer GD, Bancos I, Lee JA, Marko J, Morris-Wiseman LF, Hughes MS, Livhits MJ, Han MA, Smith PW, Wilhelm S, Asa SL, Fahey TJ 3rd, McKenzie TJ, Strong VE, Perrier ND. American Association of Endocrine Surgeons Guidelines for Adrenalectomy: Executive Summary. JAMA Surg. 2022 Oct 1;157(10):870-877. doi: 10.1001/jamasurg.2022.3544. PMID: 35976622; PMCID: PMC9386598.

Schumm M, Hu MY, Sant V, Kim J, Tseng CH, Sanz J, Raman S, Yu R, Livhits M. Automated extraction of incidental adrenal nodules from electronic health records. Surgery. 2023 Jan;173(1):52-58. doi: 10.1016/j.surg.2022.07.028. Epub 2022 Oct 4. PMID: 36207197.

M. Conall Dennedy, Anand K. Annamalai, Olivia Prankerd-Smith, Natalie Freeman, Kuhan Vengopal, Johann Graggaber, Olympia Koulouri, Andrew S. Powlson, Ashley Shaw, David J. Halsall, Mark Gurnell, Low DHEAS: A Sensitive and Specific Test for the Detection of Subclinical Hypercortisolism in Adrenal Incidentalomas, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 3, 1 March 2017, Pages 786–792, https://doi.org/10.1210/jc.2016-2718

Amar, L., Pacak, K., Steichen, O. et al. International consensus on initial screening and follow-up of asymptomatic SDHx mutation carriers. Nat Rev Endocrinol 17, 435–444 (2021). https://doi.org/10.1038/s41574-021-00492-3

**Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7

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If you liked this episode, check out other endocrine episodes here: https://behindtheknife.org/podcast-category/endocrine/