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World Class Endocrine Surgeons Gastrointestinal & Minimally Invasive Surgery Newsletter

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World Class Endocrine Surgeons Gastrointestinal & Minimally Invasive Surgery Newsletter Management of Primary Hyperaldosteronism: Updated Guidelines By Dr. Shaghayegh Aliabadi-Wahle Top Doctor, Portland Monthly Magazine, 2O11, 2O13, 2O14, 2O17 American Association of Endocrine Surgeons, American Association of Clinical Endocrinologists, American College of Surgeons GASTROINTESTINAL & he Endocrine Society’s new guidelines 5-10% of Adrenalectomy is recommended in patients Tin the management of primary with unilateral aldosterone hypersecretion MINIMALLY INVASIVE SURGERY hyperaldosteronism were recently updated. hypertensive and results in normalization of hypokalemia. They differ significantly from previous years patients will Postoperatively, hypertension is cured in in that they highlight the higher prevalence up to 60% of patients and improved in the exhibit primary Refer Your Patients - Your Way (5-10%) of this disorder in hypertensive remainder. Duration of disease and delays in patients. Furthermore, the guidelines hyperaldosteronism diagnosis are significant factors in response Save time and refer your patients underscore the fact that patients with following surgery. Medical management directly through your EMR system, primary hyperaldosteronism have a higher Aldosterone/renin ratio is used as a with mineralocorticoid receptor antagonists online at oregonclinic.com/refer, cardiovascular/renal morbidity and mortality screening test after the correction of is recommended in patients with bilateral or by phone (503) 925-3122. than age and gender matched patients with hypokalemia and the discontinuation of adrenal disease. essential hypertension for the same degree medications that may falsely impact results, Westside of blood pressure elevation. Even with such as spironolactone or eplerenone. A Greater awareness of this disorder may optimal blood pressure control, patients positive screening test is most often followed allow for more optimal management of some Downtown remain at increased cardiac risk as long as by a confirmatory test. To distinguish patients suffering from resistant hypertension. Eastside the hyper-aldosterone state persists. between unilateral and bilateral disease, the Therefore, assertive screening and treatment work up should include a CT of the abdomen Sources should be considered in high risk patients and adrenal vein sampling. The latter can JW Funder, et al, The management of primary hyperaldosteronism: Case detection, diagnosis, and with resistant or early onset hypertension, impact management in up to 50% of patients treatment: An endocrine Society clinical guideline, J Clin adrenal lesions, hypertension and sleep and is an integral part of the evaluation in Endocrinol Metab, May 2016, 101(5)1889-1916. Gastrointestinal & Minimally Invasive Surgery Newsletter apnea or hypokalemia. The absence of patients over the age of 35 years. In cases hypokalemia should not discourage an of unilateral hypersecretion, the cortisol Vol. 5 evaluation because only 9-37% of patients adjusted aldosterone level is often four times will demonstrate this. greater than the silent side. Management of Thyroid Nodules and Well Differentiated Thyroid Cancer By Dr. Shaghayegh Aliabadi-Wahle he American Thyroid Association in For lesions that ultimately prove to be identified with preoperative ultrasound neck T2015 and the American Association of benign, routine TSH suppression therapy mapping and FNA. Also of relevance, the Clinical Endocrinologists in conjunction in iodine sufficient populations is not association between higher surgeon volume with American College of Endocrinology in recommended. Operative intervention is a and a more complete oncological approach 2016 have published updated guidelines reasonable consideration in benign lesions with a lower operative complication rate in management of thyroid nodules. Their that are greater than 4 cm, enlarging, or is highlighted by the guidelines and other recommendations are certainly timely and causing compressive symptoms. Though recent literature. These recommendations relevant, given that between 2010 and 2020, surgery remains the mainstay of treatment for stress a mindful approach in evaluation diagnosis of new thyroid cancers has been malignant nodules, active surveillance can and treatment of well differentiated thyroid estimated to double. be considered for sub-centimeter, micro- malignancies. papillary carcinomas with low risk features in The guidelines emphasize that the high patients with significant co-morbidities and Sources World Class Endocrine Surgeons prevalence of thyroid nodules, most of which those with relatively short life expectancy. BR Haugen et al, 2015 American thyroid association management guidelines for adult patients with thyroid are benign, calls for a more detailed risk nodules and differentiated thyroid cancer, Thyroid 2016, The Gastrointestinal & Minimally Invasive Surgeons stratification of imaging. A five tiered system For uni-focal, low risk (1-4 cm, without 26 (1): 1-133. consisting of benign, very low suspicion, low extrathryoidal extension or clinical evidence IN THIS ISSUE: at The Oregon Clinic has a 20 year history of program, H Gharib et al, American association of clinical procedure, and instrument development. All 17 partners suspicion, intermediate suspicion and high of lymph node metastases) thyroid cancers, endocrinologists, American college of endocrinology and believe that true mastery of practice requires a dedication suspicion classification is suggested with thyroid lobectomy, or total thyroidectomy associazione medici endocrinology medical guidelines an associated risk of malignancy ranging may offer similar survival in carefully selected for clinical practice for the diagnosis and management • Management of Primary and focus on a defined field of surgery: of thyroid nodules-2016 update. Endocr Pract 2016, from less than 1% in benign patterns to patients. Patient preference and risk Hyperaldosteronism: Updated Clinical • Endocrine Surgery • General Surgery 22(5):622-39. 70—90% risk of cancer in highly suspicious of recurrence are among factors that are • Colon & Rectal • Liver, Biliary & Pancreas Guidelines lesions. This classification, along with size considered in the decision of the extent of CD Adkisson, et al, Surgeon volume and adequacy of • Gastric & Esophageal • Vein Treatment thyroidectomy for differentiated thyroid cancer. Surgery • Management of Thyroid Nodules & Well of the nodule, can guide in decision making surgery. Cervical lymph node metastasis Surgery 2014, 156(6):1453-60. Differentiated Thyroid Cancer regarding further evaluation with fine needle is identified in 20-50% of • Subclinical Cushing's Syndrome: Indication This issue focuses on our Endocrine Surgery team: Dr. aspiration, which remains the procedure of differentiated thyroid for Adrenalectomy? Richard Jamison and Dr. Shaghayegh Aliabadi-Wahle. choice in the evaluation of thyroid nodules. carcinomas, 20-30% • Management of Primary of which can be Refer Your Patients - Your Way Hyperparathyroidism: Can We Do Better? oregonclinic.com/refer (5O3) 925-3122 Subclinical Cushing's Syndrome: Indication for Adrenalectomy? About The Oregon Clinic Gastrointestinal & Minimally Invasive Surgery (GMIS) Innovation By Dr. Richard Jamison Our group has 20 years of history in program, Top Doctor, Portland Monthly Magazine, 2OO9, 2O11, 2O12, 2O16, 2O17 procedure, and instrument development. American Association of Endocrine Surgeons, American College of Surgeons Focused Areas of Expertise We are dedicated to providing high-quality drenal incidentalomas are discovered as cardiovascular risk factors including care using the latest technology. Our Aa result of imaging for other indications hypertension (67%) and diabetes (52%) in surgeons focus on the following fields of in 4-5% of patients and their incidence patients undergoing adrenalectomy. The data surgery: increases with age. Overwhelmingly, they Those who have disorders on postoperative improvement in obesity, • Endocrine Surgery represent benign, non-functioning adenomas potentially attributable dyslipidemia and bone health is encouraging, • Colon & Rectal Surgery and surgical intervention is reserved for large but remains more mixed. to excess glucocorticoid • Gastric & Esophageal Surgery (>4cm), enlarging or functional masses. In • General Surgery 5-20% of incidentalomas, a mildly increased secretion (obesity, recent In the absence of prospective randomized • Liver, Biliary & Pancreas Surgery secretion of cortisol has been documented in onset of hypertension, studies, it is reasonable to consider that • Vein Treatment the absence of clinical symptoms. diabetes, and low bone younger patients and those who have disorders potentially attributable to excess Research mass) who have well- • Active clinical and basic science Back: Drs. Newell, Hayman, Hammill, Breen, Ahmad, O’Brien, Zelko, Swanstrom & Wolf In this group, the term Subclinical Cushing's glucocorticoid secretion (obesity, recent Front: Drs. Hansen, Jamison, Aliabadi-Wahle, Dunst, Whiteford & Reavis Syndrome (SCS) has been defined as the documented glucocorticoid onset of hypertension, diabetes, and low research program Not Pictured: Drs. DeMeester & Chun abnormal response to at least two standard secretory autonomy bone mass) who have well-documented • Participation in multi-institutional tests of the hypothalamus-pituitary-adrenal glucocorticoid secretory autonomy may be research efforts Active Participation in Education axis without the usual clinical signs of may be considered for considered for adrenalectomy. Improvement
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