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Surgery Aug 2022Neuroendocrine tumors can cause ectopic Cushing syndrome, and most patients have metastatic disease at diagnosis. We identified risk factors for outcome, evaluated...
BACKGROUND
Neuroendocrine tumors can cause ectopic Cushing syndrome, and most patients have metastatic disease at diagnosis. We identified risk factors for outcome, evaluated ectopic Cushing syndrome management, and explored the role of bilateral adrenalectomy in this population.
METHODS
This was a retrospective study including patients with diagnosis of ectopic Cushing Syndrome secondary to neuroendocrine tumors with adrenocorticotropic hormone secretion treated at our quaternary referral center over a 40-year period (1980-2020).
RESULTS
Seventy-six patients were included. Mean age at diagnosis was 46.3 ± 15.8 years. Most patients (N = 61, 80%) had metastases at ectopic Cushing syndrome diagnosis. Average follow-up was 2.9 ± 3.7 years (range, 4 months-17.2 years). Patients with neuroendocrine tumors before ectopic Cushing syndrome had more frequent metastatic disease and resistant ectopic Cushing syndrome. Patients with de novo hyperglycemia, poor neuroendocrine tumor differentiation, and metastatic disease had worse survival. Of those with nonmetastatic disease, 8 (53%) had ectopic Cushing syndrome resolution after neuroendocrine tumor resection, 3 (20%) were medically controlled, and 4 (27%) underwent bilateral adrenalectomy. In patients with metastatic neuroendocrine tumors, hypercortisolism was initially medically managed in 92%, 3% underwent immediate bilateral adrenalectomy, 2% had control after primary neuroendocrine tumor debulking, and 2% were lost to follow-up. Medical treatment resulted in hormonal control in 7 (13%) patients. Of the 49 patients with metastatic disease and medically resistant ectopic Cushing syndrome, 23 ultimately had bilateral adrenalectomy with ectopic Cushing syndrome cure in all.
CONCLUSION
Patients with neuroendocrine tumors before ectopic Cushing syndrome development were more likely metastatic and had worse survival. De novo hyperglycemia and poor neuroendocrine tumor differentiation were predictive of worse prognosis. Medical control of hypercortisolism is difficult to achieve in patients with neuroendocrine tumors-ectopic Cushing syndrome. Well-selected patients may benefit from bilateral adrenalectomy early in the treatment algorithm, and multidisciplinary management is essential in this complex disease.
Topics: ACTH Syndrome, Ectopic; Adrenalectomy; Adrenocorticotropic Hormone; Cushing Syndrome; Humans; Hyperglycemia; Neuroendocrine Tumors; Retrospective Studies
PubMed: 35437162
DOI: 10.1016/j.surg.2022.03.014 -
BMC Surgery Dec 2019This retrospective clinical study is to evaluate the safety and efficiency of two different approaches in retroperitoneal laparoscopic adrenalectomy and provide...
BACKGROUND
This retrospective clinical study is to evaluate the safety and efficiency of two different approaches in retroperitoneal laparoscopic adrenalectomy and provide experience and basis for the treatment of adrenal tumors through retroperitoneal approach.
METHODS
From July 2015 to February 2018, 112 patients with adrenal lesions underwent retroperitoneal laparoscopic adrenalectomy (RLA) using a 3-port method. Among them, 56 patients underwent RLA via the extra perinephric fat approach (EPFA), 56 patients underwent RLA via the intra perinephric fat approach (IPFA). Clinical data, including preoperative, operative and postoperative management were recorded.
RESULTS
All surgeries were successfully completed, and there was no single patient who died during these surgeries. There was no statistically significant difference between the two groups in blood loss, postoperative complications, vena cava injury, renal cortex injury, peripheral organ injury, and post operation hospital stay. Peritoneum injury occurred more frequently in the EPFA group when compared with the IPEA group (p = 0.042). The average surgery time of the IPEA group is significantly shorter when compared with that of the EPEA group (p < 0.001). Due to serious saponification of the perinephric fat and heavy adhesion to renal fascia, three cases in IPFA group were converted to the EPFA surgery.
CONCLUSION
RLA is a safe and effective procedure both via extra perinephric fat and intra perinephric fat approaches. IPEA is superior to EPEA in terms of peritoneal injury and duration. The choice may mainly depend on the experience of the surgeon, the characteristics of the adrenal tumor and the nature of the perinephric fat.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Adult; Aged; Female; Humans; Kidney; Laparoscopy; Length of Stay; Male; Middle Aged; Operative Time; Peritoneum; Postoperative Complications; Retroperitoneal Space; Retrospective Studies; Treatment Outcome; Vascular System Injuries
PubMed: 31864326
DOI: 10.1186/s12893-019-0648-8 -
Frontiers in Endocrinology 2023Two adrenalectomies py -45erformed fourteen years apart notoriously alleviated insulin resistance in a female teenager with Congenital Generalized Lipoatrophy (CGL,... (Review)
Review
Two adrenalectomies py -45erformed fourteen years apart notoriously alleviated insulin resistance in a female teenager with Congenital Generalized Lipoatrophy (CGL, 1988) and in a murine model of CGL (2002). Following a successful therapeutic trial with anti-glucocorticoids, we performed the first surgical procedure on an 18-year-old girl. Before surgery, the anti-glucocorticoid therapy produced a rapid and striking drop in fasting serum insulin levels (from over 400 to 7.0 mU/L) and a slower -but impressive- fall in fasting serum triglycerides from 7,400 to 220-230 mg/dL. In contrast, fasting serum glucose levels dropped more slowly, from 225-290 to 121-138 mg/dL. Two weeks following total adrenalectomy, the fasting serum glucose level was 98 mg/dL, with a corresponding serum insulin level of 10 mU/L. During an Oral Glucose Tolerance Test, the 2-hour serum glucose was 210 mg/dL, and serum insulin values during the test did not exceed 53 mU/L. In 2002, the A-ZIP/F1 hypoleptinemic mouse had its adrenal glands removed. Even though this CGL model does not respond well to leptin replacement, an infusion of recombinant leptin reduced the characteristic hypercorticosteronemia of this murine model of CGL. Adrenalectomy in this transgenic mouse improved insulin sensitivity in the liver and muscle. In summary, adrenalectomy -in both a human and a mouse case of CGL- limited adipose tissue exposure to corticosteroid action and led to a notorious metabolic improvement. On a broader scenario, given that leptin restrains the adrenal axis, the reduced leptin activity of the leptin resistance displayed by obese subjects should lead to adrenal axis overactivity. This overactivity should result in elevated serum levels of free cortisol, free fatty acids, and glycerol. In this manner, leptin resistance should lead to peripheral (adipose tissue, liver, and muscle) insulin resistance and islet beta-cell apoptosis, paving the way to Type 2 diabetes.
Topics: Adolescent; Animals; Female; Humans; Mice; Adrenalectomy; Diabetes Mellitus, Lipoatrophic; Diabetes Mellitus, Type 2; Disease Models, Animal; Glucose; Insulin Resistance; Insulins; Leptin; Lipodystrophy, Congenital Generalized; Case Reports as Topic
PubMed: 38260129
DOI: 10.3389/fendo.2023.1151873 -
Scientific Reports Mar 2018To evaluate the therapeutic effect of single-plane retroperitoneoscopic adrenalectomy. From February 2014 to March 2017, 251 patients underwent single-plane...
To evaluate the therapeutic effect of single-plane retroperitoneoscopic adrenalectomy. From February 2014 to March 2017, 251 patients underwent single-plane retroperitoneoscopic adrenalectomy, and their operative outcomes were compared with those of 98 patients who underwent anatomical three-plane retroperitoneoscopic adrenalectomy. Among 35 patients with a body mass index (BMI) of ≥30 kg/m, their operative outcomes were compared between two operative procedures. The demographic data and perioperative outcomes of the patients were statistically analysed. The single-plane and three-plane groups were comparable in terms of estimated blood loss, time to oral intake, hospital stay, and incidence of complications among patients with similar baseline demographics. The single-plane group had a significantly shorter operation time (46.9 ± 5.8 vs 54.8 ± 7.0 mins, P < 0.0001) and lower analgesia requirement (56/251 vs 33/98, p = 0.03). For obese patients with a BMI of ≥30 kg/m, single-plane adrenalectomy was also associated with a significantly shorter operation time(48.1 ± 6.2 vs 64.1 ± 5.1 mins, p < 0.0001). Single-plane retroperitoneoscopic adrenalectomy is feasible, safe, and effective in the treatment of adrenal masses <5 cm in size and provides a shorter operation time and better pain control than anatomical retroperitoneal adrenalectomy, especially in obese patients.
Topics: Adrenal Gland Diseases; Adrenalectomy; Adult; Body Mass Index; Female; Humans; Male; Middle Aged; Retroperitoneal Space; Treatment Outcome
PubMed: 29507374
DOI: 10.1038/s41598-018-22433-3 -
Surgical Endoscopy Dec 2020The superiority of laparoscopic transperitoneal (TP) versus retroperitoneal (RP) adrenalectomy is an ongoing debate.
Laparoscopic transperitoneal and retroperitoneal adrenalectomy: a 20-year, single-institution experience with an analysis of the learning curve and tumor size [lap transper and retroper adrenalectomy].
BACKGROUND
The superiority of laparoscopic transperitoneal (TP) versus retroperitoneal (RP) adrenalectomy is an ongoing debate.
METHODS
Data from 163 patients (TP: n = 135; RP: n = 28) undergoing minimally invasive adrenalectomy were analyzed. Both operative [intraoperative blood loss, previous abdominal surgery, conversion rate, operative time and tumor size] and perioperative [BMI (body mass index), ASA (American Society of Anesthesiologists) score, time of hospitalization, time of oral intake, histology and postoperative complications] parameters were compared. Both the learning curve (LC) and tumor size were analyzed.
RESULTS
We found significant differences in the mean operative time (p = 0.019) and rate of previous abdominal surgery (p = 0.038) in favor of TP. Significantly larger tumors were removed with TP (p = 0.018). Conversion rates showed no significant difference (p = 0.257). Also, no significant differences were noted for time of hospitalization, intraoperative blood loss and postoperative complications. In terms of the LC, we saw significant differences in previous abdominal surgery (p = 0.015), conversion rate (p = 0.011) and operative time (p = 0.023) in favor of TP. Large (LT) and extra-large tumors (ELT) were involved in 47 lesions (LT: 40 vs. ELT: 7), with a mean tumor size of 71.85 and 141.57 mm, respectively. Mean intraoperative blood loss was 64.47 ml vs. 71.85 ml, time of hospitalization was 5.10 vs. 4.57 days and mean operative time was 76.52 vs. 79.28 min for LT and ELT, respectively.
CONCLUSION
A shorter operative time and lower conversion rate in favor of TP were noted during the learning curve. TP proved to be more effective in the removal of large-, extra-large and malignant lesions. The RP approach was feasible for smaller, benign lesions, with a more prolonged learning curve.
Topics: Adrenalectomy; Female; Humans; Laparoscopy; Learning Curve; Male; Middle Aged; Operative Time; Retroperitoneal Space
PubMed: 31953726
DOI: 10.1007/s00464-019-07337-1 -
BMC Endocrine Disorders Oct 2017The hypertension cure rate of unilateral adrenalectomy in primary aldosteronism (PA) patients varies widely in existing studies. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The hypertension cure rate of unilateral adrenalectomy in primary aldosteronism (PA) patients varies widely in existing studies.
METHODS
We conducted an observational meta-analysis to summarize the pooled hypertension cure rate of unilateral adrenalectomy in PA patients. Comprehensive electronic searches of PubMed, Embase, Cochrane, China National Knowledge Internet (CNKI), WanFang, SinoMed and Chongqing VIP databases were performed from initial state to May 20, 2016. We manually selected eligible studies from references in accordance with the inclusion criteria. The pooled hypertension cure rate of unilateral adrenalectomy in PA patients was calculated using the DerSimonian-Laird method to produce a random-effects model.
RESULTS
Forty-three studies comprising approximately 4000 PA patients were included. The pooled hypertension cure rate was 50.6% (95% CI: 42.9-58.2%) for unilateral adrenalectomy in PA. Subgroup analyses showed that the hypertension cure rate was 61.3% (95% CI: 49.4-73.3%) in Chinese studies and 43.7% (95% CI: 38.0-49.4%) for other countries. Furthermore, the hypertension cure rate at 6-month follow-up was 53.3% (95% CI: 36.0-70.5%) and 49.6% (95% CI: 40.9-58.3%) for follow-up exceeding 6 months. The pooled hypertension cure rate was 50.9% (95% CI: 40.5-61.3%) from 2001 to 2010 and 50.2% (95% CI: 39.0-61.5%) from 2011 to 2016.
CONCLUSIONS
The hypertension cure rate for unilateral adrenalectomy in PA is not optimal. Large clinical trials are required to verify the utility of potential preoperative predictors in developing a novel and effective prediction model.
Topics: Adrenalectomy; Humans; Hyperaldosteronism; Hypertension; Treatment Outcome
PubMed: 28974210
DOI: 10.1186/s12902-017-0209-z -
JAMA Surgery Apr 2019In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of...
IMPORTANCE
In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of antihypertensive medications with a subsequent decreased risk of cardiovascular and/or cerebrovascular morbidity and drug-induced adverse effects.
OBJECTIVE
To evaluate the change in BP and use of antihypertensive medications within an international cohort of patients who recently underwent surgery for primary aldosteronism.
DESIGN, SETTING, AND PARTICIPANTS
A cohort study was conducted across 16 referral medical centers in Europe, the United States, Canada, and Australia. Patients who underwent unilateral adrenalectomy for primary aldosteronism between January 2010 and December 2016 were included. Data analysis was performed from August 2017 to June 2018. Unilateral disease was confirmed using computed tomography, magnetic resonance imaging, and/or adrenal venous sampling. Patients with missing or incomplete preoperative or follow-up data regarding BP or corresponding number of antihypertensive medications were excluded.
MAIN OUTCOMES AND MEASURES
Clinical success was defined based on postoperative BP and number of antihypertensive medications. Cure was defined as normotension without antihypertensive medications, and clear improvement as normotension with lower or equal use of antihypertensive medications. In patients with preoperative normotensivity, improvement was defined as postoperative normotension with lower antihypertensive use. All other patients were stratified as no clear success because the benefits of surgery were less obvious, mainly owing to postoperative, persistent hypertension. Clinical outcomes were assessed at follow-up closest to 6 months after surgery.
RESULTS
On the basis of inclusion and exclusion criteria, a total of 435 patients (84.6%) from a cohort of 514 patients who underwent unilateral adrenalectomy were eligible. Of these patients, 186 (42.3%) were women; mean (SD) age at the time of surgery was 50.7 (11.4) years. Cure was achieved in 118 patients (27.1%), clear improvement in 135 (31.0%), and no clear success in 182 (41.8%). In the subgroup classified as no clear success, 166 patients (91.2%) had postoperative hypertension. However, within this subgroup, the mean (SD) systolic and diastolic BP decreased significantly by 9 (22) mm Hg (P < .001) and 3 (15) mm Hg (P = .04), respectively. Also, the number of antihypertensive medications used decreased from 3 (range, 0-7) to 2 (range, 0-6) (P < .001). Moreover, in 75 of 182 patients (41.2%) within this subgroup, the decrease in systolic BP was 10 mm Hg or greater.
CONCLUSIONS AND RELEVANCE
In this study, for most patients, adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. Furthermore, a significant proportion of patients with postoperative, persistent hypertension may benefit from adrenalectomy given the observed clinically relevant and significant reduction of BP and antihypertensive medications.
Topics: Adrenalectomy; Adult; Aged; Antihypertensive Agents; Blood Pressure; Diastole; Female; Humans; Hyperaldosteronism; Hypertension; Male; Middle Aged; Systole; Treatment Outcome
PubMed: 30810749
DOI: 10.1001/jamasurg.2018.5842 -
Journal of the Formosan Medical... Mar 2024Primary aldosteronism (PA) is the most common cause of secondary hypertension and one of the few medical diseases that can be cured by surgery. Excessive aldosterone... (Review)
Review
Primary aldosteronism (PA) is the most common cause of secondary hypertension and one of the few medical diseases that can be cured by surgery. Excessive aldosterone secretion is highly associated with cardiovascular complications. Many studies have shown that patients with unilateral PA treated with surgery have better survival, cardiovascular, clinical, and biochemical outcomes than those who receive medical treatment. Consequently, laparoscopic adrenalectomy is the gold standard for treating unilateral PA. Surgical methods should be individualized according to the patient's tumor size, body shape, surgical history, wound considerations, and surgeon's experience. Surgery can be performed through a transperitoneal or retroperitoneal approach, and via a single-port or multi-port laparoscopic approach. However, total or partial adrenalectomy remains controversial in treating unilateral PA. Partial excision will not completely eradicate the disease and is prone to recurrence. Mineralocorticoid receptor antagonists should be considered for patients with bilateral PA or patients who cannot undergo surgery. There are also emerging alternative interventions, including radiofrequency ablation and transarterial adrenal ablation, for which data on long-term outcomes are currently lacking. The Task Force of Taiwan Society of Aldosteronism developed these clinical practice guidelines with the aim of providing medical professionals with more updated information on the treatment of PA and improving the quality of care.
Topics: Humans; Taiwan; Hyperaldosteronism; Adrenalectomy; Hypertension; Mineralocorticoid Receptor Antagonists
PubMed: 37328332
DOI: 10.1016/j.jfma.2023.05.032 -
Nihon Hinyokika Gakkai Zasshi. the... Sep 1993Since January, 1992, 8 patients with adrenal disease have been treated by laparoscopic surgery. There were 4 males and 4 females (35-65 years old), seven patients had...
Since January, 1992, 8 patients with adrenal disease have been treated by laparoscopic surgery. There were 4 males and 4 females (35-65 years old), seven patients had primary aldosteronism and one non-functioning adrenal tumor. Six trocar-sheath units were placed in the upper abdomen. In case of the lesion being on the right side, the posterior layer of the peritoneum was incised at the point of the hepatic flexure of the colon and on the left side, the dissection was begun by dividing the peritoneal reflection over the lateral aspect of the descending colon, adrenal tumors were removed with normal adrenal gland. In all cases adrenal tumors were removed successfully. The operative time was from 165 to 572 (293 min., average) minutes and there was no major complication.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Adult; Aged; Female; Humans; Hyperaldosteronism; Laparoscopy; Male; Middle Aged
PubMed: 8411823
DOI: 10.5980/jpnjurol1989.84.1675 -
Medicina 2022Unilateral primary aldosteronism (PA) is the most common surgically correctable cause of hypertension. Determination of success after laparoscopic adrenalectomy (LA) is...
Unilateral primary aldosteronism (PA) is the most common surgically correctable cause of hypertension. Determination of success after laparoscopic adrenalectomy (LA) is limited by the lack of standardized criteria. We sought to evaluate the surgical recurrence and functional outcomes of LA in patients with Conn's syndrome applying the primary aldosteronism surgical outcome (PASO) Criteria. Descriptive observational analysis of patients treated with LA due to confirmed u nilateral Conn's syndrome between May 2007 and August 2020: Twenty patients were included in the cohort; 16 patients had TLA and other four PLA [58% male, median age 47 (IQR: 44-59.5) years and median follow-up of 64 (IQR: 2-156) ] months. Median tumor size was 1.2 (0.8-1.8) cm. No conversions to open surgery were recorded and the overall morbidity of the series was 1/20. No surgical or biochemical recurrence was observed. Five patients were excluded from the analysis of functional results due to lack of follow-up. According to the PASO criteria, complete, partial, and no success were observed in 8/15, 6/15, and 1/15, respectively. The surgical treatment of the disease is supported by the literature, and we were able to reproduce the results of other series. The use of standardized and reproducible criteria to assess its functional results would be essential for a more complete and integrated evaluation of adrenal surgery.
Topics: Adrenalectomy; Adult; Cohort Studies; Female; Humans; Hyperaldosteronism; Laparoscopy; Male; Middle Aged; Treatment Outcome
PubMed: 35904911
DOI: No ID Found