EDITORIAL COMMENT
ENDOCRINOLOGY AND THE SURGEON ENDOCRINE surgery developed rapidly following the brillant introduction of thyroidectomy by Kocher. He was one of the only two Nobel Laureates in surgery, and he demonstrated quite clearly that when carried out precisely, endocrine surgery provided great satisfaction to both surgeon and patient. When his surgery was a little too aggressive he learned of hypothyroidism. Healso learned of the hidden problems in this form of surgery when he observed hypoparathyroidism. Kocher's skill, operative precision, and postoperative observation provided the basic trends for modern endocrine surgery .
M u l t i p l e endocrine adenopathy is being diagnosed mor5 frequently. Recognition of such a syndrome follows awareness of the possibility of its occurrence. Some patients have problems needing solutions which carry potential risks for them during investigation, e.g., Sipple's syndrome, wherein medullary carcinoma of the t h y r o i d and phaeochromocytoma are coincident. In such a case, unless there is some compelling feature such as tracheal obstruction, the phaeochromocytoma should be excised first with all the attendent precautions that surgeon, anaesthetist, and endocrinologist can provide.
Even a decade ago the ductless glands and their internal secretions were well codified. However, more recently there has been a relative explosion of knowledge of new hormones on both the laboratory and the clinical scene. Many organs have been found to elaborate hormones or similar substances and in doing so have provided new challenges in clinical management. Prime among these have been hormones of the gastrointestinal tract and those organs which bud off from it during embryonic development
With these syndromes it can be seen that accuracy in diagnosis isessential. The development of radioimmunoassay has allowed the measurement of a number of hormones, such as gastrin, parathroid hormone, and triiodothyronine, so allowing for further precision in diagnosis. The precision of measurement of a hormone must be combined with an appropriate patient work-up and if needed definitive surgery, if the best results are to be obtained. Such definition of purpose has been clearly demonstrated in relation to prolactin excess. Once it became possible to assay prolactin, the problems of infertility and impotence associated with excess secretion were found to be controllable by the dopamine agonist bromocriptine. The excessive prolactin secretion has been found to be due to microadenomata of the pituitary. Such microadenomata and some causing Cushing's disease have been selectively excised by transsphenoidal microtechniques. This approach would appear to have a bright future.
Also observed have been ectopic sources of hormones from neoplasms of lung, ovary, pancreas and other organs. So well defined are the hormonal functions that removal of the malignant lesion leads to control of hormonal effect, and recurrence of the lesion leads to a reappearance of their activity. The APUD series of tumours presumably of neural origin are hormone-producing tumours arising along the intestine at any level, or in organs that arise from the alimentary tract (pancreas and biliary tree) early in embryonic life. Some tumours in this area are already well described, such as gastrinoma and the ZollingerEllison syndrome, while others are almost certainly waiting for the astute clinician and the inventive chemist to find both tumour and hormone and to describe the syndrome eponymously. Reprints T S Reeve, The Royal North Shore Hospital of Sydney, St Leonards. N S W 2065
AUST N.Z. J. SURG., VOL.48-No. 3, JUNE, 1978
Endocrine surgery is in a dynamic phase, its scope is body wide, and it offers challenges to surgical skill that are matched only by the chemist u n r a v e l l i n g t h e new h o r m o n e s a n d t h e endocrinologist observing the physical dangers caused by addition or removal of these subtances to the body economy. There is an opportunity for surgeons to join this clinical field. It will, however, exact its tithe from each of its acolytes. Close follow-up in the long term
235
HARE
EDITORIAL COMMENT
is necessary in all patients who have undergone surgery for endocrine disorders. Manifestations of recurrent disease or evidence of dysfunction may not develop until some years after surgeryand many not be readily observed by the patient. The surgeon
and the endocrine team must provide this ongoing surveillance to maintain the reputation of this exciting field. T. S. REEVE
ORGAN IMAGING THEability to visualize abnormalities in internal organs is increasing rapidly through advances i n nuclear medicine, ultrasound, and the innovation of computerized tomography (CT), with the prospect of further exciting developments to come. The emergence of the term “organ imaging” recognizes the broadening spectrum of radiations employed, but also points to the fundamental nature of these recent advances. X-rays can distinguish between air, soft tissue organsand calcification, but w i t h i n s o f t t i s s u e o r g a n s t h e r e is l i t t l e differentiation; parenchyma, muscle, blood, and connective tissues being of equal radiodensity. The newer modalities, in varying degrees, overcome this problem. Nuclear images portray the pattern of tissue uptake of circulating isotope, the ultrasound picture is built u p of echoes produced at tissue interfaces, and CT is a sophistication of conventional radiography in which a computer analyses the emerging beam and reconstructs a grey scale picture from the data. The availability of these newer methodsof investigation, often with few guidelines for use, might understandably confuse clinicians. Certainly, the prospect of such a range of expensive tests being readily available for ambulatory patients is of considerable concern to the Government. In the United States of America there are already installed about 700 CT scanners, and in California alone, with a population of about that of Australia, there are 150 machines operating. I n England and Wales, for a population of 49 million, 28 head and seven body CT scanners have been established. The contrast between these countries reflects the different health care systemsand is rather ironical in that CT was a British invention. In Australia the first head CT scanners were installed in public hospitals in 1975, but growth i n that sector has been relatively slow because of financial restrictions, despite the proven value of CT, at least in the head. Development in the private sector, where conditions are similar to those in the U.S.A., has been more rapid.
236
Currently there are about 20 CT scanners in operation, placing Australia amongst the best-served nations in this respect. Previous advances i n imaging, such as angiography, were invasive and required hospitalization. This limited the rate of spread to the community, and provided time for adequate evaluation, and education of the profession. This does not apply to the newer techniques of organ imaging. which are diffusing rapidly with the attendant risks of overutilization and inappropriate utilization. The concern of health insurance agencies would appear justified from the American experience, which provoked the introduction in 1976 of the “Certificate of Need” legislation, by which a Federal permit is required to start a new clinic service or to purchase equipment worth more than $100,000. Clearly, in this country, as we approach the limit of available health dollars, the profession is obliged to develop a rational approach to the introduction of these diagnostic tests. The various methods of imaging are not competitive, but complementary, and it is logical that they should be grouped together so that methods appropriate to each clinical situation are readily available. The trends for radiology departments to become organ imaging departments is established, and the Royal Australasian College of Radiologists already requires training in the broad spectrum of diagnostic methods. Clinicians and diagnosticians s h o u l d c o n s u l t c o n c e r n i n g p r o t o c o l s for investigating particular clinical situations, making best use of the resources available and effecting economies. Primary care doctors performing their own imaging examinations are faced with the problems of “self-reterral”, and this is perhaps most likely with ultrasound, which appears free from harm to the patient. Even the referral specialists, including radiologists, have a problem when the findings on initial examination require further elucidation by AUST.N.Z. J. SURG, VOL 48-No.
3, JUNE,1978
ENDOCRINOLOGY AND THE SURGEON ENDOCRINE surgery developed rapidly following the brillant introduction of thyroidectomy by Kocher. He was one of the only two Nobel Laureates in surgery, and he demonstrated quite clearly that when carried out precisely, endocrine surgery provided great satisfaction to both surgeon and patient. When his surgery was a little too aggressive he learned of hypothyroidism. Healso learned of the hidden problems in this form of surgery when he observed hypoparathyroidism. Kocher's skill, operative precision, and postoperative observation provided the basic trends for modern endocrine surgery .
M u l t i p l e endocrine adenopathy is being diagnosed mor5 frequently. Recognition of such a syndrome follows awareness of the possibility of its occurrence. Some patients have problems needing solutions which carry potential risks for them during investigation, e.g., Sipple's syndrome, wherein medullary carcinoma of the t h y r o i d and phaeochromocytoma are coincident. In such a case, unless there is some compelling feature such as tracheal obstruction, the phaeochromocytoma should be excised first with all the attendent precautions that surgeon, anaesthetist, and endocrinologist can provide.
Even a decade ago the ductless glands and their internal secretions were well codified. However, more recently there has been a relative explosion of knowledge of new hormones on both the laboratory and the clinical scene. Many organs have been found to elaborate hormones or similar substances and in doing so have provided new challenges in clinical management. Prime among these have been hormones of the gastrointestinal tract and those organs which bud off from it during embryonic development
With these syndromes it can be seen that accuracy in diagnosis isessential. The development of radioimmunoassay has allowed the measurement of a number of hormones, such as gastrin, parathroid hormone, and triiodothyronine, so allowing for further precision in diagnosis. The precision of measurement of a hormone must be combined with an appropriate patient work-up and if needed definitive surgery, if the best results are to be obtained. Such definition of purpose has been clearly demonstrated in relation to prolactin excess. Once it became possible to assay prolactin, the problems of infertility and impotence associated with excess secretion were found to be controllable by the dopamine agonist bromocriptine. The excessive prolactin secretion has been found to be due to microadenomata of the pituitary. Such microadenomata and some causing Cushing's disease have been selectively excised by transsphenoidal microtechniques. This approach would appear to have a bright future.
Also observed have been ectopic sources of hormones from neoplasms of lung, ovary, pancreas and other organs. So well defined are the hormonal functions that removal of the malignant lesion leads to control of hormonal effect, and recurrence of the lesion leads to a reappearance of their activity. The APUD series of tumours presumably of neural origin are hormone-producing tumours arising along the intestine at any level, or in organs that arise from the alimentary tract (pancreas and biliary tree) early in embryonic life. Some tumours in this area are already well described, such as gastrinoma and the ZollingerEllison syndrome, while others are almost certainly waiting for the astute clinician and the inventive chemist to find both tumour and hormone and to describe the syndrome eponymously. Reprints T S Reeve, The Royal North Shore Hospital of Sydney, St Leonards. N S W 2065
AUST N.Z. J. SURG., VOL.48-No. 3, JUNE, 1978
Endocrine surgery is in a dynamic phase, its scope is body wide, and it offers challenges to surgical skill that are matched only by the chemist u n r a v e l l i n g t h e new h o r m o n e s a n d t h e endocrinologist observing the physical dangers caused by addition or removal of these subtances to the body economy. There is an opportunity for surgeons to join this clinical field. It will, however, exact its tithe from each of its acolytes. Close follow-up in the long term
235
HARE
EDITORIAL COMMENT
is necessary in all patients who have undergone surgery for endocrine disorders. Manifestations of recurrent disease or evidence of dysfunction may not develop until some years after surgeryand many not be readily observed by the patient. The surgeon
and the endocrine team must provide this ongoing surveillance to maintain the reputation of this exciting field. T. S. REEVE
ORGAN IMAGING THEability to visualize abnormalities in internal organs is increasing rapidly through advances i n nuclear medicine, ultrasound, and the innovation of computerized tomography (CT), with the prospect of further exciting developments to come. The emergence of the term “organ imaging” recognizes the broadening spectrum of radiations employed, but also points to the fundamental nature of these recent advances. X-rays can distinguish between air, soft tissue organsand calcification, but w i t h i n s o f t t i s s u e o r g a n s t h e r e is l i t t l e differentiation; parenchyma, muscle, blood, and connective tissues being of equal radiodensity. The newer modalities, in varying degrees, overcome this problem. Nuclear images portray the pattern of tissue uptake of circulating isotope, the ultrasound picture is built u p of echoes produced at tissue interfaces, and CT is a sophistication of conventional radiography in which a computer analyses the emerging beam and reconstructs a grey scale picture from the data. The availability of these newer methodsof investigation, often with few guidelines for use, might understandably confuse clinicians. Certainly, the prospect of such a range of expensive tests being readily available for ambulatory patients is of considerable concern to the Government. In the United States of America there are already installed about 700 CT scanners, and in California alone, with a population of about that of Australia, there are 150 machines operating. I n England and Wales, for a population of 49 million, 28 head and seven body CT scanners have been established. The contrast between these countries reflects the different health care systemsand is rather ironical in that CT was a British invention. In Australia the first head CT scanners were installed in public hospitals in 1975, but growth i n that sector has been relatively slow because of financial restrictions, despite the proven value of CT, at least in the head. Development in the private sector, where conditions are similar to those in the U.S.A., has been more rapid.
236
Currently there are about 20 CT scanners in operation, placing Australia amongst the best-served nations in this respect. Previous advances i n imaging, such as angiography, were invasive and required hospitalization. This limited the rate of spread to the community, and provided time for adequate evaluation, and education of the profession. This does not apply to the newer techniques of organ imaging. which are diffusing rapidly with the attendant risks of overutilization and inappropriate utilization. The concern of health insurance agencies would appear justified from the American experience, which provoked the introduction in 1976 of the “Certificate of Need” legislation, by which a Federal permit is required to start a new clinic service or to purchase equipment worth more than $100,000. Clearly, in this country, as we approach the limit of available health dollars, the profession is obliged to develop a rational approach to the introduction of these diagnostic tests. The various methods of imaging are not competitive, but complementary, and it is logical that they should be grouped together so that methods appropriate to each clinical situation are readily available. The trends for radiology departments to become organ imaging departments is established, and the Royal Australasian College of Radiologists already requires training in the broad spectrum of diagnostic methods. Clinicians and diagnosticians s h o u l d c o n s u l t c o n c e r n i n g p r o t o c o l s for investigating particular clinical situations, making best use of the resources available and effecting economies. Primary care doctors performing their own imaging examinations are faced with the problems of “self-reterral”, and this is perhaps most likely with ultrasound, which appears free from harm to the patient. Even the referral specialists, including radiologists, have a problem when the findings on initial examination require further elucidation by AUST.N.Z. J. SURG, VOL 48-No.
3, JUNE,1978
