Tracy S. Wang, M.D., M.P.H., F.A.C.S.*
Department of Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226, USA
Abstract. The increasing complexity in the management of surgical disorders of the thyroid, parathy-
roid, adrenal glands, and neuroendocrine pancreas tumors have led to the emergence of endocrine
surgery as a surgical subspecialty. Studies showing the relationship between hospital/surgeon volume
and patient outcomes highlight the importance of advanced postgraduate training in this field.
© 2011 Elsevier Inc. All rights reserved.
The discipline of endocrine surgery encompasses the
surgical management of disorders of the thyroid, parathy-
roid, and adrenal glands and neuroendocrine tumors of the
pancreas and gastrointestinal tract. The management of pa-
tients with surgical endocrine disease is intellectually stim-
ulating and often complex, requiring a multidisciplinary
team of endocrinologists, radiologists, pathologists, and sur-
geons. Over the past several decades, as the incidence of
surgical endocrine disorders has increased, endocrine sur-
gery has emerged as a recognized specialty within the dis-
cipline of general surgery.
The increasing incidence of diseases of the thyroid, para-
thyroid, and adrenal glands is likely a combination of im-
proved radiographic imaging and diagnostic techniques as
well as a true increase in the incidence of disease.1,2Primary
hyperparathyroidism affects 1 in 500 women and 1 in 2,000
men older than age 40 years, with an incidence of 100,000
new cases each year.3Palpable thyroid nodules are present
in 4% to 7% of American adults and thyroid cancer, with an
estimated 37,000 new cases in 2007, accounts for 1.5% of
all new cancers in the United States.4,5Incidental adrenal
nodules have been reported in up 4% of abdominal com-
puted tomography scans and up to 32% of autopsy stud-
There also have been advances in the understanding of
the pathophysiology and genetic basis for surgical endo-
crine diseases. As diagnostic modalities and radiographic
imaging techniques have improved, the preoperative, intra-
operative, and postoperative management of patients has
become more refined and increasingly intricate, involving
multimodality preoperative imaging, minimally invasive
procedures, intraoperative parathyroid hormone monitoring,
radio-guided parathyroid surgery, laparoscopy, video-as-
sisted surgery, and, more recently, robotic surgery. Despite
this growing complexity in surgical technique, studies have
shown that across the United States, most endocrine proce-
dures (thyroidectomy, parathyroidectomy, and adrenalec-
tomy) are performed by surgeons whose practice is not
focused on endocrine surgery. Saunders et al8analyzed data
from the National Inpatient Sample between 1988 and 2000
and found that surgeons whose practice was made up of less
than 25% of endocrine procedures performed 82% of all
thyroidectomies, 78% of parathyroidectomies, and 94% of
adrenalectomies. Surgeons with more than 76% endocrine
practices made up only 1% of all surgeons performing
thyroidectomy, parathyroidectomy, and adrenalectomy.8
One possible explanation for these findings is that grad-
uating general surgery chief residents have a highly variable
experience in endocrine procedures, with the majority hav-
ing minimal exposure to endocrine surgery. In a review of
data from the Residency Review Committee, Harness et
al9,10showed that most residents have inadequate experi-
ence in thyroid, parathyroid, and adrenal surgery. The most
* Corresponding author. Tel.: ?1-414-805-5755; fax: ?1-414-805-
E-mail address: firstname.lastname@example.org
Manuscript received July 17, 2010; revised manuscript July 28, 2010
0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
The American Journal of Surgery (2011) 202, 369–371
of thyroidectomies performed ranged from 7 to 10 per
graduating resident; this decreased to a common number 2
parathyroidectomies and no adrenalectomies or neuroendo-
crine pancreatectomies. Sosa et al11found that graduating
chief residents performed just 11% of the average experi-
ence of endocrine surgery fellows.
However, surgical volume has been shown to be associ-
ated with improved patient outcomes. Birkmeyer et al12
found that higher hospital volume was linked to decreased
mortality for 14 cardiovascular and oncologic procedures.
Surgeon volume also is associated with improved outcomes;
based on Maryland data, surgeons performing 100 or more
thyroidectomies had the fewest complications, with no as-
sociation observed between hospital volume and out-
comes.13High surgeon volume also has been linked to
improved outcomes in children and in elderly patients un-
dergoing thyroidectomy and parathyroidectomy.14,15
For all the earlier-described reasons, advanced postgrad-
uate training in endocrine surgery for general surgery resi-
dents seeking to develop expertise in the management of
surgical endocrine diseases is essential.
Fellowship training in Endocrine Surgery
Endocrine surgery fellowships are sponsored by the
American Association of Endocrine Surgeons (AAES). In
response to the growing need for advanced postgraduate
training and the emergence of endocrine surgery fellow-
ships at several high-volume centers, the Education and
Research Committee of the AAES developed a formal fel-
lowship curriculum, which was ratified by the AAES Ex-
ecutive Council in 2005. The curriculum was designed to
ensure similar high-quality training across different institu-
tions; overall objectives are as follows:
● Show knowledge and understanding of endocrine gland
anatomy and physiology, both the normal and pathologic
● Show the ability to diagnose clinical endocrinopathies
associated with endocrine surgical diseases;
● Develop knowledge of the inherited endocrine disorders
and understand the role of genetic counseling and testing;
● Have an appreciation of the current controversies and
current areas of research in the literature within endocrine
surgical diseases; and
● Show the ability to apply this knowledge and safely
perform the appropriate surgery for a given endocrine
A formal curriculum also has been created for general
At present, there are no Board examinations for gradu-
ating fellows. There are 19 clinical fellowships in the United
States, most of which are 1 year in length. Fellowship
programs participate in the AAES match program. The
application process should begin 1 academic year before the
anticipated date of entry to the fellowship. Further informa-
tion on the fellowship, including a list of programs and
requirements, can be found at the AAES web site (available:
Membership in societies
The AAES is the premier organization for this specialty.
Established in 1980, its mission is the “advancement of the
science and art of endocrine surgery and maintenance of
high standards in the practice of endocrine surgery.” Active
membership is limited to surgeons who are Fellows of the
American College of Surgeons or its international equiva-
lent and who have a major interest and devote significant
portions of his/her practice or research to endocrine surgery.
Active members must be certified by the American Board of
Surgery or its equivalent in Canada, Central, or South
America and have attended at least 1 prior meeting of the
AAES. Surgeons who have completed their surgical train-
ing and are awaiting qualifications to become an active
member may apply for candidate membership in the AAES;
a letter of sponsorship from an active or senior AAES
member is required. Resident/fellow membership is limited
to those in a residency, research, or clinical fellowship
The AAES annual meeting is held each spring. The
AAES encourages the submission of abstracts by residents
and fellows for the annual meeting; prizes are awarded to
the best resident/fellow articles in both clinical and basic
science research. Prizes also are awarded for the poster
competition and interesting case sessions. More information
on the AAES can be found at http://www.endocrinesurgery.
Other surgical organizations of interest include the So-
ciety of Surgical Oncology, International Association of
Endocrine Surgeons, Australian Endocrine Surgeons, Brit-
ish Association of Endocrine and Thyroid Surgeons, Asian
Association of Endocrine Surgeons, and the American So-
ciety for Head and Neck Surgery. Nonsurgical societies
include the American Association of Clinical Endocrinolo-
gists, American Society of Clinical Oncology, the Endo-
crine Society, and the American Thyroid Association.
1. Chen AY, Jemal A, Ward EM. Increasing incidence of differentiated
thyroid cancer in the United States, 1988–2005. Cancer 2009;115:
2. Davies L, Welch HG. Increasing incidence of thyroid cancer in the
United States, 1973–2002. JAMA 2006;295:2164–7.
3. Lal G, Clark OH. Diagnosis of primary hyperparathyroidism and
indications for parathyroidectomy. In: Clark OH, Duh QY, Kebebew
E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia: Elsevier
370The American Journal of Surgery, Vol 202, No 3, September 2011
4. Hegedüs L. Clinical practice. The thyroid nodule. N Engl J Med
5. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer
J Clin 2008;58:71.
6. Kloos RT, Gross MD, Francis IR, et al. Incidentally discovered adrenal
masses. Endocr Rev 1995;16:460–84.
7. Bovio S, Cataldi A, Reimondo G, et al. Prevalence of adrenal inci-
dentaloma in a contemporary computerized tomography series. J En-
docrinol Invest 2006;29:298–302.
8. Saunders BD, Wainess RM, Dimick JB, et al. Who performs endocrine
operations in the United States? Surgery 2003;134:924–31.
9. Harness JK, Organ CH, Thompson NW. Operative experience of U.S.
general surgery residents with diseases of the adrenal glands, endo-
crine pancreas, and other less common endocrine organs. World J Surg
10. Harness JK, Organ CH, Thompson NW. Operative experience of U.S.
general surgery residents in thyroid and parathyroid disease. Surgery
11. Sosa JA, Wang TS, Yeo HL, et al. The maturation of a specialty: work-
force projections for endocrine surgery. Surgery 2007;142:876–83.
12. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and
surgical mortality in the United States. N Engl J Med 2002;346:1128–37.
13. Sosa JA, Bowman HM, Tielsch JM, et al. The importance of surgeon
experience for clinical and economic outcomes from thyroidectomy.
Ann Surg 1998;228:320–30.
14. Sosa JA, Tuggle CT, Wang TS, et al. Clinical and economic outcomes
of thyroid and parathyroid surgery in children. J Clin Endocrinol
15. Tuggle CT, Roman SA, Wang TS, et al. Pediatric endocrine surgery:
who is operating on our children? Surgery 2008;144:869–77.
371 T.S. Wang Endocrine surgery