Endocrine Surgery in Cirrhotic Patients



Cirrhosis with chronic liver failure is a disease capable of affecting a variety of organ systems. As the prevalence of chronic liver disease increases, more patients undergoing elective surgery will have concomitant liver failure (O’Leary et al. 13:211, 2009). It is well documented that cirrhotic patients undergoing procedures under general anesthesia have perioperative mortality ranging from 8.3% to 25% (Millwala et al. 13:4056–4063, 2007). As the liver plays a vital function in a number of metabolic pathways, dysfunction of the liver can target several endocrine organs. As such, surgical management of endocrine disorders requires astute knowledge of the role of advanced liver disease in endocrine disorders and prudent judgment in the selection of patients that will undergo surgery.


Thyroid surgery Thyroid nodules Cirrhosis Advanced liver disease Adrenal surgery Hyperparathyroidism Endocrine disorders 


  1. 1.
    Bianco AC, Larsen PR. Intracellular pathways of iodothyronine metabolism. In: Braverman LE, Utiger RD, editors. The Thyroid: Fundamental and Clinical Text. Philadelphia: Lippincott Williams and Wilkins; 2005.Google Scholar
  2. 2.
    Burra P. Liver abnormalities and endocrine diseases. Best Pract Res Clin Gastroenterol. 2013;27:553–63.CrossRefPubMedGoogle Scholar
  3. 3.
    Burra P, Franklyn JA, Ramsden DB, Elias E, Sheppard MC. Severity of alcoholic liver disease and markers of thyroid and steroid status. Postgrad Med J. 1992;68:804–10.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Antonelli A, Ferri C, Fallahi P, et al. Thyroid cancer in HCV-related chronic hepatitic patients: a case-control study. Thyroid. 2007;17:447–51.CrossRefPubMedGoogle Scholar
  5. 5.
    Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid. 2009;19:1159.CrossRefPubMedGoogle Scholar
  7. 7.
    Friedman LS. The risk of surgery in patients with liver disease. Hepatology. 1999;29:1617.CrossRefPubMedGoogle Scholar
  8. 8.
    Ziser A, Plevak DJ, Wiesner RH, et al. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Anesthesiology. 1999;90:42.CrossRefPubMedGoogle Scholar
  9. 9.
    Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132:1261.CrossRefPubMedGoogle Scholar
  10. 10.
    Friedman LS, Maddrey WC. Surgery in the patient with liver disease. Med Clin North Am. 1987;71:453.CrossRefPubMedGoogle Scholar
  11. 11.
    Malinchoc M, Kamath PS, Gordon FD, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31:864.CrossRefPubMedGoogle Scholar
  12. 12.
    Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for end-stage liver disease (MELD) predicts non-transplant surgical mortality in patients with cirrhosis. Ann Surg. 2005;242:244–51.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Pons Y, Gauthier J, Ukkola-Pons E, et al. Comparison of LigaSure vessel sealing system, harmonic scalpel, and conventional hemostasis in total thyroidectomy. Otolaryngol Head Neck Surg. 2009;141:496.CrossRefPubMedGoogle Scholar
  14. 14.
    Siperstein AE, Berber E, Morkoyun E. The use of the harmonic scalpel vs. conventional knot tying for vessel ligation in thyroid surgery. Surgery. 2002;137:137–42.Google Scholar
  15. 15.
    Ecker T, Carvalho AL, Choe JH, et al. Hemostasis in thyroid surgery: harmonic scalpel versus other techniques–a meta-analysis. Otolaryngol Head Neck Surg. 2010;143:17.CrossRefPubMedGoogle Scholar
  16. 16.
    Silverberg SJ, Bilezikian JP. Evaluation and management of primary hyperparathyroidism. J Clin Endocrinol Metab. 1996;81:2036.PubMedGoogle Scholar
  17. 17.
    Oldenburg WA, Van Heerden PA, Sizemore GW, Abbound CF, Sheedy PF. Hypercalcemia and primary hepatic tumors. Arch Surg. 1982;117:1363–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Luo JC, Hwang SJ, Wu JC, et al. Paraneoplastic syndromes in patients with hepatocellular carcinoma in Taiwan. Cancer. 1999;86:799–804.CrossRefPubMedGoogle Scholar
  19. 19.
    Luo JC, Hwang SJ, Wu JC, Lai CR, Li CP, Chang FY, Chiang JH, Lui WY, Chu CW, Lee SD. Clinical characteristics and prognosis of hepatocellular carcinoma patients with paraneoplastic syndromes. Hepatogastroenterology. 2002;49:1315–9.PubMedGoogle Scholar
  20. 20.
    Forrest KY, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults. Nutr Res. 2011;31:48.CrossRefPubMedGoogle Scholar
  21. 21.
    Grey A, Lucas J, Horne A, et al. Vitamin D repletion in patients with primary hyperparathyroidism and coexistent vitamin D insufficiency. J Clin Endocrinol Metab. 2005;90:2122.CrossRefPubMedGoogle Scholar
  22. 22.
    Compston JE. Hepatic osteodystrophy: vitamin D metabolism in patients with liver disease. Gut. 1986;27:1073.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Kumar R. Hepatic and intestinal osteodystrophy and the hepatobiliary metabolism of vitamin D. Ann Intern Med. 1983;98:662.CrossRefPubMedGoogle Scholar
  24. 24.
    Sun J. Vitamin D and mucosal immune function. Curr Opin Gastroenterol. 2010;26:591–5.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Bitetto D, Fabris C, Fornasiere E, Pipan C, Fumolo E, Cussigh A, et al. Vitamin D supplementation improves response to antiviral treatment for recurrent hepatitis C. Transpl Int. 2011;24:43–50.CrossRefPubMedGoogle Scholar
  26. 26.
    Petta S, Camma C, Scazzone C, Tripodo C, Di Marco V, Bono A, et al. Low vitamin D serum level is related to severe fibrosis and low responsiveness to interferon-based therapy in genotype 1 chronic hepatitis C. Hepatology. 2010;51:1158–67.CrossRefPubMedGoogle Scholar
  27. 27.
    Bitetto D, Fabris C, Falleti E, Fornasiere E, Fumolo E, Fontanini E, et al. Vitamin D and the risk of acute allograft rejection following human liver transplantation. Liver Int. 2010;30:417–44.CrossRefPubMedGoogle Scholar
  28. 28.
    Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99:3561.CrossRefPubMedGoogle Scholar
  29. 29.
    Haber RS, Kim CK, Inabnet WB. Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with (99 m)technetium sestamibi scintigraphy. Clin Endocrinol (Oxf). 2002;57:241.CrossRefGoogle Scholar
  30. 30.
    Eslamy HK, Ziessman HA. Parathyroid scintigraphy in patients with primary hyperparathyroidism: 99mTc sestamibi SPECT and SPECT/CT. Radiographics. 2008;28:1461.CrossRefPubMedGoogle Scholar
  31. 31.
    Kwon JH, Kim EK, Lee HS, et al. Neck ultrasonography as preoperative localization of primary hyperparathyroidism with an additional role of detecting thyroid malignancy. Eur J Radiol. 2013;82:e17.CrossRefPubMedGoogle Scholar
  32. 32.
    Nichols KJ, Tomas MB, Tronco GG, et al. Preoperative parathyroid scintigraphic lesion localization: accuracy of various types of readings. Radiology. 2008;248:221.CrossRefPubMedGoogle Scholar
  33. 33.
    Norman J, Lopez J, Politz D. Abandoning unilateral parathyroidectomy: why we reversed our position after 15,000 parathyroid operations. J Am Coll Surg. 2012;214(3):260–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Siperstein A, Berber E, Mackey R, Alghoul M, Wagner K, Milas M. Prospective evaluation of sestamibi scan, ultrasonography, and rapid PTH to predict the success of limited exploration for sporadic primary hyperparathyroidism. Surgery. 2004;136(4):872–80.CrossRefPubMedGoogle Scholar
  35. 35.
    Day KM, Elsayed M, Monchik JM. No need to abandon focused unilateral exploration for primary hyperparathyroidism with intraoperative monitoring of intact parathyroid hormone. J Am Coll Surg. 2015;221(2):518–23.CrossRefPubMedGoogle Scholar
  36. 36.
    Norlén O, Wang KC, Tay YK, et al. No need to abandon focused parathyroidectomy: a multicenter study of long-term outcome after surgery for primary hyperparathyroidism. Ann Surg. 2015;261(5):991–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Slepavicius A, Beisa V, Janusonis V, Strupas K. Focused versus conventional parathyroidectomy for primary hyperparathyroidism: a prospective, randomized, blinded trial. Langenbecks Arch Surg. 2008;393:659.CrossRefPubMedGoogle Scholar
  38. 38.
    Westerdahl J, Bergenfelz A. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial. Ann Surg. 2007;246:976.CrossRefPubMedGoogle Scholar
  39. 39.
    Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg (Published online August). 2016;10 doi: 10.1001/jamasurg.2016.2310.
  40. 40.
    Bovio S, Cataldi A, Reimondo G, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest. 2006;29:298.CrossRefPubMedGoogle Scholar
  41. 41.
    Terzolo M, Stigliano A, Chiodini I, et al. AME position statement on adrenal incidentaloma. Eur J Endocrinol. 2011;164:851.CrossRefPubMedGoogle Scholar
  42. 42.
    Katyal S, Oliver 3rd JH, Peterson MS, Ferris JV, Carr BS, Baron RL. Extrahepatic metastases of hepatocellular carcinoma. Radiology. 2000;216:698–703.CrossRefPubMedGoogle Scholar
  43. 43.
    Fassnacht M, Allolio B. Clinical management of adrenocortical carcinoma. Best Pract Res Clin Endocrinol Metab. 2009;23:273.CrossRefPubMedGoogle Scholar
  44. 44.
    Eisenhofer G, Goldstein DS, Walther MM, Friberg P, Lenders JWM, Keiser HR, Pacak K. Biochemical diagnosis of pheochromocytoma: how to distinguish true- from false-positive test results. J Clin Endocrinol Metab. 2003;88:2656–66.CrossRefPubMedGoogle Scholar
  45. 45.
    Vilar L, Freitas Mda C, Faria M, et al. Pitfalls in the diagnosis of Cushing’s syndrome. Arq Bras Endocrinol Metabol. 2007;51:1207–16.CrossRefPubMedGoogle Scholar
  46. 46.
    Hamrahian AH, Ioachimescu AG, Remer EM, et al. Clinical utility of noncontrast computed tomography attenuation value (hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland Clinic experience. J Clin Endocrinol Metab. 2005;90:871.CrossRefPubMedGoogle Scholar
  47. 47.
    Rossi H, Kim A, Prinz RA. Primary hyperaldosteronism in the era of laparoscopic adrenalectomy. Am Surg. 2002;68:253.PubMedGoogle Scholar
  48. 48.
    Välimäki M, Pelkonen R, Porkka L, et al. Long-term results of adrenal surgery in patients with Cushing’s syndrome due to adrenocortical adenoma. Clin Endocrinol (Oxf). 1984;20:229.CrossRefGoogle Scholar
  49. 49.
    Amar L, Servais A, Gimenez-Roqueplo AP, et al. Year of diagnosis, features at presentation, and risk of recurrence in patients with pheochromocytoma or secreting paraganglioma. J Clin Endocrinol Metab. 2005;90:2110.CrossRefPubMedGoogle Scholar
  50. 50.
    Herrera MF, Grant CS, van Heerden JA, et al. Incidentally discovered adrenal tumors: an institutional perspective. Surgery. 1991;110:1014.PubMedGoogle Scholar
  51. 51.
    Angeli A, Osella G, Alì A, Terzolo M. Adrenal incidentaloma: an overview of clinical and epidemiological data from the National Italian Study Group. Horm Res. 1997;47:279.CrossRefPubMedGoogle Scholar
  52. 52.
    Lee JE, Evans DB, Hickey RC, et al. Unknown primary cancer presenting as an adrenal mass: frequency and implications for diagnostic evaluation of adrenal incidentalomas. Surgery. 1998;124(6):1115–22.CrossRefPubMedGoogle Scholar
  53. 53.
    Hornstein I, Schwarz C, Ebbing S, Hoppe-Lotichius M, Otto G, Lang H, Musholt TJ. Surgical resection of metastases to the adrenal gland: a single center experience. Langenbecks Arch Surg. 2015;400(3):333–9. doi: 10.1007/s00423-015-1293-z. Epub 2015 Mar 1. PubMed PMID: 25726026.CrossRefPubMedGoogle Scholar
  54. 54.
    Ha TY, Hwang S, Ahn CS, Kim KH, Lee YJ, Moon DB, Song GW, Jung DH, Park GC, Lee SG. Resection of metachronous adrenal metastasis after liver resection and transplantation for hepatocellular carcinoma. Dig Surg. 2014;31(6):428–35. doi: 10.1159/000370078. Epub 2015 Jan 7.CrossRefPubMedGoogle Scholar
  55. 55.
    Lee J, El-Tamer M, Schifftner T, et al. Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program. J Am Coll Surg. 2008;206:953.CrossRefPubMedGoogle Scholar
  56. 56.
    Henry J, Sebag F, Iacobone M, et al. Results of laparoscopic adrenalectomy for large and potentially malignant tumors. World J Surg. 2002;26:1043.CrossRefPubMedGoogle Scholar
  57. 57.
    Ramacciato G, Mercantini P, Torre ML, et al. Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm? Surg Endosc. 2008;22:516.CrossRefPubMedGoogle Scholar
  58. 58.
    Walz MK, Alesina PF, Wenger FA, et al. Posterior retroperitoneoscopic adrenalectomy–results of 560 procedures in 520 patients. Surgery. 2006;140:943.CrossRefPubMedGoogle Scholar
  59. 59.
    Taskin HE, Berber E. Robotic adrenalectomy. Cancer J. 2013;19:162.CrossRefPubMedGoogle Scholar
  60. 60.
    Yamakado K, Anai H, Takaki H, et al. Adrenal metastasis from hepatocellular carcinoma: radiofrequency ablation combined with adrenal arterial chemoembolization in 6 patients. AJR Am J Roentgenol. 2009;192:W300–5.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.EssentiaHealth/Duluth ClinicDuluthUSA
  2. 2.Cleveland ClinicClevelandUSA

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