Endocrine Metabolic response to trauma/stress "Glucose intolerance" aka high glucose Increased glycogenolysis in liver and gluconeogensis 2/2 increased glucagon Insulin resistance 2/2 increased cortisol - glucose uptake decreased Insulin concentrations higher Steroids given in acute spinal cord injury and ARDS increase infectious complications. Neuroendocine tumors of pancreas hypervascular ususally indolent radioresistant liver mets not a contraindication to resection of primary (can do wedge resection while at it), don't have to take out mets right away, or at all. Diffuse toxic goiter (Grave's disease) Radioablation is tx of choice Subtotal thyroidectomy less popular - recurrent goiter occurs 10-20% at 10y, 40% at 30y If re-operate for diffuse toxic goiter, increased risk of permanent hypoparathyroidism Substernal goiter - should be resected early (subtotal) to avoid complications - airway obstruction, SVC syndrome, RLN or phrenic n compression. Thyroid storm IVF with glucose (storm accelerates glucose metabolism), steroids (storm causes relative adrenal insufficiency), (ASA worsens storm by displacing T4 from thyroglobulin), B-blockade prevents conversion of T4 to T3, PTU, KI (afterPTU) Intra-op PTH Doesn't affect OR time, cost, stay, morbidity, mortality It does definitively tell you that the abnormal tissue has been removed. Parathyroid CA Rare Presents as hyperparathyroidism Tx: resection of involved gland, ipsilateral thyroid, and regional nodes If recurrent disease, resection usually not curative, but can be used to palliate sx of hypercalcemia If widely metastatic and want to palliate hi Ca - IVF, loop diuretics, bisphosphonates Medullary Thyroid CA Total thyroidectomy + central nod dissection (hyoid to innominate v, between carotids) Papillary thyroid cancer Tx of virtually all papillary or follicular thyroid CA >1.5 cm: total or near total thyroidectomy f/b radioiodine You can ablate an entire lobe with radioiodine, but the radiation required approaches toxic dose, so you limit options for recurrence. Cervical nodal metastases: 50% incidence of micromets to cervical nodes Elective nodal dissection in absence of clinically positive dz not recommended. If lateral nodes detected, modified neck dissection (preserve SCM, spinal accessory, IJ). Don't just remove the enlarged nodes (although that's what Norton does). If nodes appear later (20%), do regional neck dissection then, with no decrease in survival. Node positivity does not impact survival. Node positivity does not affect rate of local recurrence. Risk factor to develop cervical node mets: age > 70, extrathyroid invasion of primary, blood vessel invasion, hi grade Post-thyroidectomy hypocalcemia: risk factors- h/o hyperthyroidism, esp Grave's (hungry bone syndrome), extent of thyroid resection, autotransplantation (takes a while for them to revascularize)