Adrenalectomy

Last updated
Adrenalectomy
Adrenal Tumor.JPG
Adrenalectomy
ICD-10-PCS 0GB2-0GB4 for excision,
0GT2-0GT4 for resection
ICD-9-CM 07.2-07.3
MeSH D000315
MedlinePlus 007437

Adrenalectomy (Latin root Ad "near/at" + renal "related to the kidneys" + Greek ‑ectomy “out-cutting”; sometimes written as ADX for the procedure or resulting state) [1] [2] is the surgical removal of one (unilateral) or both (bilateral) adrenal glands. It is usually done to remove tumors of the adrenal glands that are producing excess hormones or is large in size (more than 2 inches or 4 to 5 centimeters). Adrenalectomy can also be done to remove a cancerous tumor of the adrenal glands, or cancer that has spread from another location, such as the kidney or lung. Adrenalectomy is not performed on those who have severe coagulopathy or whose heart and lungs are too weak to undergo surgery. The procedure can be performed using an open incision (laparotomy) or minimally invasive laparoscopic or robot-assisted techniques. [3] Minimally invasive techniques are increasingly the gold standard of care due to shorter length of stay in the hospital, lower blood loss, and similar complication rates. [3] [4]

Contents

Diagram showing the position of the adrenal glands Diagram showing the position of the adrenal glands CRUK 343.svg
Diagram showing the position of the adrenal glands

One adrenal gland sits above each kidney. The two adrenal glands produce hormones (steroid hormones and catecholamines) that help regulate blood pressure, blood sugar level, metabolism, immune system, stress and other essential functions. If one adrenal gland is removed, the other adrenal gland will take over the hormone-producing role. If both adrenal glands are removed, the patient will require lifelong steroid supplementation. [5]

Indications

Incidences and prognoses of adrenal tumors; over half of which are benign (noncancerous). Incidences and prognoses of adrenal tumors.png
Incidences and prognoses of adrenal tumors; over half of which are benign (noncancerous).

Most adrenal tumors are noncancerous (benign), often found incidentally as a mass via imaging such as CT scans, MRI, or ultrasound that were taken for other health workups (see incidentaloma). Although these adrenal masses do require evaluation, the majority of them (approximately 80% [7] ) do not require adrenalectomy. However, due to the hormone-producing function of the adrenal glands, some noncancerous adrenal tumors may produce too much hormones, such as aldosterone (called primary aldosteronism), cortisol (called Cushing's disease or Cushing's syndrome), or catecholamines (called pheochromocytoma). These hormone-producing tumors may need adrenalectomy. Additionally, adrenal tumors that are larger than 4 centimeters in size, regardless of whether they produce hormones, also require adrenalectomy due to increased risk of adrenal cancer. Rarely (5–12%), the adrenal tumor may be cancerous (adrenocortical carcinoma), requiring adrenalectomy. Rarer still, the mass may be a metastatic cancer that spread from another location, such as the kidney or lung. If the metastasis is isolated to the adrenal gland, it may be a candidate for adrenalectomy. [5] [7]

Contraindications

An absolute contraindication (a reason not to do the surgery under any situation) for adrenalectomy are patients who are generally unsuited to surgery: having severe coagulopathy and poor cardiopulmonary performance due to the stress to the body that surgery will produce. In addition, American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons guidelines state minimally-invasive techniques should be avoided when there is a large tumor size (larger than 6 cm) due to difficulties in maneuvering around a large mass, and in adrenocortical carcinoma where there is a risk of not fully removing the cancerous tissue. [3] [7] However, at least one meta-analysis of 898 patients has found shorter length of stay, less blood loss, and no higher rates of complications even in large (>5 cm) tumors using minimally-invasive techniques. [8]

Techniques

Techniques for adrenalectomy is largely divided into two types: open surgical laparotomy versus minimally invasive techniques.

Open surgery

Surgeons usually reserve open surgery for large (larger than 6 cm) or cancerous tumors where there is a risk of not fully removing the cancerous tissue. They perform open surgery using traditional instruments and cuts (incisions). [7]

Minimally invasive techniques

Minimally invasive techniques may be laparoscopic, where several small cuts (incisions) are made to allow for the surgeon to directly control surgical instruments with their hands while visualizing the surgery via a tiny camera that provides a magnified, 3D view of the surgical site. Laparoscopic surgery has many benefits. For example, this surgery has smaller scars, less pain, less blood loss, similar complication rates, and a shorter recovery period than traditional open surgery. [8] [3] Traditionally, this has been through the laparoscopic transperitoneal approach (LTA) where the small cuts are made in the abdomen to reach the adrenal glands through the peritoneum from the front-side.

However, an alternative approach is possible called retroperitoneoscopic adrenalectomy (PRA), where the adrenal glands are reached through small cuts made in the back. Studies have shown that both LTA and PRA are equally safe and effective, though some suggest advantages of PRA over LTA in terms of lower intensity of postoperative pain, shorter hospital stay, faster recovery, and lower early morbidity. A 2018 systematic review suggests that laparoscopic retroperotenial adrenalectomy appears to reduce late morbidity, time to oral fluid or food intake and time to ambulation when compared to laparoscopic transperitoneal adrenalectomy; however, there is uncertainty about these effects due to very low-quality evidence. [9] For outcomes such as all-cause mortality, early morbidity, socioeconomic effects, and operative and postoperative parameter, the evidence is uncertain about the effects of either interventions over the other. [9] PRA involves high pressure CO₂ within a limited retroperitoneal space, and therefore may cause kidney injury in those at high risk. [4]

Sometimes surgeons perform robot-assisted adrenalectomies. They perform the surgery through small cuts (incisions) using robotic arms with a camera and instruments attached. The camera gives doctors a high-definition, magnified, 3D view of the surgical site. No significant differences were found between laparoscopic and robot-assisted adrenalectomy in two meta-analyses for complications, blood loss, or mortality, however robotic adrenalectomy had shorter hospital stays at the cost of longer operating time and higher cost of surgery. [4] [10] [3]

Postoperative

Postoperative care is highly dependent on what the adrenalectomy was performed for. After adrenalectomy for a cortisol-producing adenoma, patients should be treated with exogenous glucocorticoids such as cortisone or hydrocortisone until the hypothalamic-pituitary-adrenal (HPA) axis has recovered. This process may take 6 to 18 months after unilateral adrenalectomy. Similarly, for patients who have undergone adrenalectomy for (subclinical) Cushing syndrome, perioperative glucocorticoid therapy and postoperative assessment of HPA axis recovery are necessary. For patients who have undergone adrenalectomy for a pheochromocytoma, long-term followup is necessary because 10-15% of patients may have recurrence. [7] For those with high blood pressure (secondary hypertension) from primary aldosteronism, adrenalectomy provides a clinical cure rate of approximately 27.1%. [11]

If both adrenal glands are removed, the patient can no longer create the adrenal hormones necessary for life (primary adrenal insufficiency). Signs and symptoms include volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain. This requires lifetime treatment with the hormones produced by the removed adrenal glands, including glucocorticoids and mineralocorticoids (fludrocortisone). The glucocorticoid dose needs to be increased when in stress or during infections or else adrenal crisis may occur. [5] [12]

For women with deficiency in androgens as a result of the loss of androgen production from the adrenal glands following adrenalectomy, dehydroepiandrosterone (DHEA) replacement can be considered. The signs and symptoms include low libido, depressive symptoms, and/or low energy levels despite optimized glucocorticoid and mineralocorticoid replacement. [7] [5]

Complications

Complications from an adrenalectomy can include insufficient cortisol production, acute kidney injury, post-operative bleeding, damage to nearby organs, and post-operative infection.

See also

Related Research Articles

<span class="mw-page-title-main">Adrenal gland</span> Endocrine gland

The adrenal glands are endocrine glands that produce a variety of hormones including adrenaline and the steroids aldosterone and cortisol. They are found above the kidneys. Each gland has an outer cortex which produces steroid hormones and an inner medulla. The adrenal cortex itself is divided into three main zones: the zona glomerulosa, the zona fasciculata and the zona reticularis.

<span class="mw-page-title-main">General surgery</span> Medical specialty

General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid gland. They also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral artery disease and hernias and perform endoscopic as such as gastroscopy, colonoscopy and laparoscopic procedures.

<span class="mw-page-title-main">Laparoscopy</span> Minimally invasive operations within the abdominal or pelvic cavities

Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.

<span class="mw-page-title-main">Cushing's syndrome</span> Symptoms from excessive exposure to glucocorticoids such as cortisol

Cushing's syndrome is a collection of signs and symptoms due to prolonged exposure to glucocorticoids such as cortisol. Signs and symptoms may include high blood pressure, abdominal obesity but with thin arms and legs, reddish stretch marks, a round red face due to facial plethora, a fat lump between the shoulders, weak muscles, weak bones, acne, and fragile skin that heals poorly. Women may have more hair and irregular menstruation. Occasionally there may be changes in mood, headaches, and a chronic feeling of tiredness.

<span class="mw-page-title-main">Pheochromocytoma</span> Type of neuroendocrine tumor

Pheochromocytoma is a rare tumor of the adrenal medulla composed of chromaffin cells, also known as pheochromocytes. When a tumor composed of the same cells as a pheochromocytoma develops outside the adrenal gland, it is referred to as a paraganglioma. These neuroendocrine tumors typically release massive amounts of catecholamines which result in the most common symptoms, including hypertension, tachycardia, and sweating. Rarely, some tumors may secrete little to no catecholamines, making diagnosis difficult. While tumors of the head and neck are parasympathetic, their sympathetic counterparts are predominantly located in the abdomen and pelvis, particularly concentrated at the organ of Zuckerkandl.

Cushing's disease is one cause of Cushing's syndrome characterised by increased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary. This is most often as a result of a pituitary adenoma or due to excess production of hypothalamus CRH that stimulates the synthesis of cortisol by the adrenal glands. Pituitary adenomas are responsible for 80% of endogenous Cushing's syndrome, when excluding Cushing's syndrome from exogenously administered corticosteroids. The equine version of this disease is Pituitary pars intermedia dysfunction.

<span class="mw-page-title-main">Primary aldosteronism</span> Medical condition

Primary aldosteronism (PA), also known as primary hyperaldosteronism, refers to the excess production of the hormone aldosterone from the adrenal glands, resulting in low renin levels and high blood pressure. This abnormality is caused by hyperplasia or tumors. About 35% of the cases are caused by a single aldosterone-secreting adenoma, a condition known as Conn's syndrome.

<span class="mw-page-title-main">Adrenal insufficiency</span> Medical condition

Adrenal insufficiency is a condition in which the adrenal glands do not produce adequate amounts of steroid hormones. The adrenal glands—also referred to as the adrenal cortex—normally secrete glucocorticoids, mineralocorticoids, and androgens. These hormones are important in regulating blood pressure, electrolytes, and metabolism as a whole. Deficiency of these hormones leads to symptoms ranging from abdominal pain, vomiting, muscle weakness and fatigue, low blood pressure, depression, mood and personality changes to organ failure and shock. Adrenal crisis may occur if a person having adrenal insufficiency experiences stresses, such as an accident, injury, surgery, or severe infection; this is a life-threatening medical condition resulting from severe deficiency of cortisol in the body. Death may quickly follow.

<span class="mw-page-title-main">Endocrine surgery</span>

Endocrine surgery is a surgical sub-speciality focusing on surgery of the endocrine glands, including the thyroid gland, the parathyroid glands, the adrenal glands, glands of the endocrine pancreas, and some neuroendocrine glands.

<span class="mw-page-title-main">Parathyroidectomy</span> Surgical removal of one or more of the parathyroid glands

Parathyroidectomy is the surgical removal of one or more of the (usually) four parathyroid glands. This procedure is used to remove an adenoma or hyperplasia of these glands when they are producing excessive parathyroid hormone (PTH): hyperparathyroidism. The glands are usually four in number and located adjacent to the posterior surface of the thyroid gland, but their exact location is variable. When an elevated PTH level is found, a sestamibi scan or an ultrasound may be performed in order to confirm the presence and location of abnormal parathyroid tissue.

<span class="mw-page-title-main">Adrenocortical carcinoma</span> Medical condition

Adrenocortical carcinoma (ACC) is an aggressive cancer originating in the cortex of the adrenal gland.

<span class="mw-page-title-main">Nephrectomy</span> Surgical removal of a kidney

A nephrectomy is the surgical removal of a kidney, performed to treat a number of kidney diseases including kidney cancer. It is also done to remove a normal healthy kidney from a living or deceased donor, which is part of a kidney transplant procedure.

<span class="mw-page-title-main">Cystectomy</span> Surgical removal of all or part of the bladder

Cystectomy is a medical term for surgical removal of all or part of the urinary bladder. It may also be rarely used to refer to the removal of a cyst. The most common condition warranting removal of the urinary bladder is bladder cancer.

<span class="mw-page-title-main">Multiple endocrine neoplasia type 1</span> Medical condition

Multiple endocrine neoplasia type 1 (MEN-1) is one of a group of disorders, the multiple endocrine neoplasias, that affect the endocrine system through development of neoplastic lesions in pituitary, parathyroid gland and pancreas. Individuals suffering from this disorder are prone to developing multiple endocrine and nonendocrine tumors. It was first described by Paul Wermer in 1954.

Secondary hypertension is a type of hypertension which by definition is caused by an identifiable underlying primary cause. It is much less common than the other type, called essential hypertension, affecting only 5-10% of hypertensive patients. It has many different causes including endocrine diseases, kidney diseases, and tumors. It also can be a side effect of many medications.

Nelson's syndrome is a disorder that occurs in about one in four patients who have had both adrenal glands removed to treat Cushing's disease. In patients with pre-existing adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas, loss of adrenal feedback following bilateral adrenalectomy can trigger the rapid growth of the tumor, leading to visual symptoms and hyperpigmentation. The severity of the disease is dependent upon the effect of ACTH release on the skin, pituitary hormone loss from mass compression, as well as invasion into surrounding structures around the pituitary gland.

<span class="mw-page-title-main">Adrenal tumor</span> Medical condition

An adrenal tumor or adrenal mass is any benign or malignant neoplasms of the adrenal gland, several of which are notable for their tendency to overproduce endocrine hormones. Adrenal cancer is the presence of malignant adrenal tumors, and includes neuroblastoma, adrenocortical carcinoma and some adrenal pheochromocytomas. Most adrenal pheochromocytomas and all adrenocortical adenomas are benign tumors, which do not metastasize or invade nearby tissues, but may cause significant health problems by unbalancing hormones.

<span class="mw-page-title-main">Adrenocortical adenoma</span> Medical condition

An adrenocortical adenoma or adrenal adenoma is commonly described as a benign neoplasm emerging from the cells that comprise the adrenal cortex. Like most adenomas, the adrenocortical adenoma is considered a benign tumor since the majority of them are non-functioning and asymptomatic. Adrenocortical adenomas are classified as ACTH-independent disorders, and are commonly associated with conditions linked to hyperadrenalism such as Cushing's syndrome (hypercortisolism) or Conn's syndrome (hyperaldosteronism), which is also known as primary aldosteronism. In addition, recent case reports further support the affiliation of adrenocortical adenomas with hyperandrogenism or florid hyperandrogenism which can cause hyperandrogenic hirsutism in females. "Cushing's syndrome" differs from the "Cushing's disease" even though both conditions are induced by hypercortisolism. The term "Cushing's disease" refers specifically to "secondary hypercortisolism" classified as "ACTH-dependent Cushing's syndrome" caused by pituitary adenomas. In contrast, "Cushing's syndrome" refers specifically to "primary hypercortisolism" classified as "ACTH-independent Cushing's syndrome" caused by adrenocortical adenomas.

<span class="mw-page-title-main">Parathyroid adenoma</span> Medical condition

A parathyroid adenoma is a benign tumor of the parathyroid gland. It generally causes hyperparathyroidism; there are very few reports of parathyroid adenomas that were not associated with hyperparathyroidism.

<span class="mw-page-title-main">Adrenalism</span>

Adrenalism describes the condition of an excessive or substandard secretion of hormones related to the adrenal glands, which are found directly superior to the kidneys. Adrenalism can be further distinguished as hyperadrenalism, referring to the excessive secretion of hormones, and hypoadrenalism, referring to the insufficient secretion of hormones.

References

  1. Gemmill ME, Eskay RL, Hall NL, Douglass LW, Castonguay TW (February 2003). "Leptin suppresses food intake and body weight in corticosterone-replaced adrenalectomized rats". The Journal of Nutrition. 133 (2): 504–509. doi: 10.1093/jn/133.2.504 . PMID   12566491. Some of these effects are reportedly enhanced in bilaterally adrenalectomized (ADX) rats.
  2. Reincke M, Albani A, Assie G, Bancos I, Brue T, Buchfelder M, et al. (March 2021). "Corticotroph tumor progression after bilateral adrenalectomy (Nelson's syndrome): systematic review and expert consensus recommendations". European Journal of Endocrinology. 184 (3): P1–P16. doi:10.1530/EJE-20-1088. PMC   8060870 . PMID   33444221.
  3. 1 2 3 4 5 Heger P, Probst P, Hüttner FJ, Gooßen K, Proctor T, Müller-Stich BP, et al. (November 2017). "Evaluation of Open and Minimally Invasive Adrenalectomy: A Systematic Review and Network Meta-analysis". World Journal of Surgery. 41 (11): 2746–2757. doi:10.1007/s00268-017-4095-3. PMID   28634842. S2CID   4729192.
  4. 1 2 3 Kozłowski T, Rydzewska-Rosolowska A, Myśliwiec J, Choromańska B, Wojskowicz P, Dadan J, et al. (2019). "The impact of laparoscopic adrenalectomy on renal function. Results of a prospective randomised clinical trial". Endokrynologia Polska. 70 (5): 409–416. doi: 10.5603/EP.a2019.0029 . PMID   31274187. S2CID   195806068.
  5. 1 2 3 4 Li AY, Dream S (2022). "Adrenalectomy". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   32644519 . Retrieved 2022-11-22.
  6. Data and references for pie chart are located at file description page in Wikimedia Commons.
  7. 1 2 3 4 5 6 Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D, et al. (2009-07-01). "The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas". Endocrine Practice. 15 Suppl 1: 1–20. doi: 10.4158/EP.15.S1.1 . PMID   19632967.
  8. 1 2 Gan L, Meng C, Li K, Li J, Wu J, Li Y (August 2022). "Safety and effectiveness of minimally invasive adrenalectomy versus open adrenalectomy in patients with large adrenal tumors (≥5 cm): A meta-analysis and systematic review". International Journal of Surgery. 104: 106779. doi:10.1016/j.ijsu.2022.106779. PMID   35870758. S2CID   250937601.
  9. 1 2 Arezzo A, Bullano A, Cochetti G, Cirocchi R, Randolph J, Mearini E, et al. (Cochrane Metabolic and Endocrine Disorders Group) (December 2018). "Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for adrenal tumours in adults". The Cochrane Database of Systematic Reviews. 2018 (12): CD011668. doi:10.1002/14651858.CD011668.pub2. PMC   6517116 . PMID   30595004.
  10. Economopoulos KP, Mylonas KS, Stamou AA, Theocharidis V, Sergentanis TN, Psaltopoulou T, Richards ML (February 2017). "Laparoscopic versus robotic adrenalectomy: A comprehensive meta-analysis". International Journal of Surgery. 38: 95–104. doi: 10.1016/j.ijsu.2016.12.118 . PMID   28043926.
  11. Manosroi W, Atthakomol P, Phinyo P, Inthaphan P (2022-08-18). "Predictive factors of clinical success after adrenalectomy in primary aldosteronism: A systematic review and meta-analysis". Frontiers in Endocrinology. 13: 925591. doi: 10.3389/fendo.2022.925591 . PMC   9434311 . PMID   36060937.
  12. "Adrenalectomy". surgerydoor.co.uk. Archived from the original on 2009-04-29. Retrieved 2021-12-04.