Adrenal Size Research Articles

Risk Factors for Perioperative Complications of Laparoscopic Adrenalectomy Including Single-Site Surgery

To determine predictive factors for perioperative complications of laparoscopic adrenalectomy (LA) including single-site surgery performed or supervised by experienced laparoscopic surgeons. We retrospectively reviewed 265 consecutive unilateral LAs performed at a single institution from 2001 to 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. The transabdominal approach was used in 248 patients, while a retroperitoneal approach was used in 17 patients. Laparoendoscopic single-site adrenalectomy was performed in 58 patients. Predictive factors for postoperative complications were analyzed. There were no postoperative deaths. At least one postoperative complication occurred in 12 (4.6%) patients. No patient underwent reoperation for a complication. Only one (0.4%) patient's procedure was converted to open surgery, and only this patient needed a blood transfusion during the operation. One patient who underwent laparoendoscopic single-site adrenalectomy had the procedure converted to conventional laparoscopic adrenalectomy. Multivariable logistic regression analysis showed that an American Society of Anesthesiologists-physical status grade 3 or above was the only predictive factor for perioperative complications. American Society of Anesthesiologists-physical status grade 3 or above was a statistically significant factor for perioperative complications associated with laparoscopic adrenalectomy that involved laparoendoscopic single-site adrenalectomy, which was performed or supervised by an experienced laparoscopic surgeon. According to the findings of this retrospective study, single-site operation, obesity, adrenal tumor size, and tumor type may not be considered as risk factors for perioperative complications after LA performed or supervised by an experienced laparoscopic surgeon.

Late gestation undernutrition can predispose for visceral adiposity by altering fat distribution patterns and increasing the preference for a high-fat diet in early postnatal life

We have developed a sheep model to facilitate studies of the fetal programming effects of mismatched perinatal and postnatal nutrition. During the last trimester of gestation, twenty-one twin-bearing ewes were fed a normal diet fulfilling norms for energy and protein (NORM) or 50% of a normal diet (LOW). From day 3 postpartum to 6 months (around puberty) of age, one twin lamb was fed a conventional (CONV) diet and the other a high-carbohydrate-high-fat (HCHF) diet, resulting in four groups of offspring: NORM-CONV; NORMHCHF; LOW-CONV; LOW-HCHF. At 6 months of age, half of the lambs (all males and three females) were slaughtered for further examination and the other half (females only) were transferred to a moderate sheep diet until slaughtered at 24 months of age (adulthood). Maternal undernutrition during late gestation reduced the birth weight of LOW offspring (P<0·05), and its long-term effects were increased adrenal size in male lambs and adult females (P<0·05), increased neonatal appetite for fat-(P=0·004) rather than carbohydrate-rich feeds (P<0·001) and reduced deposition of subcutaneous fat in both sexes (P<0·05). Furthermore, LOW-HCHF female lambs had markedly higher visceral:subcutaneous fat ratios compared with the other groups (P<0·001). Postnatal overfeeding (HCHF) resulted in obesity (.30% fat in soft tissue) and widespread ectopic lipid deposition. In conclusion, our sheep model revealed strong pre- and postnatal impacts on growth, food preferences and fat deposition patterns. The present findings support a role for subcutaneous adipose tissue in the development of visceral adiposity, which in humans is known to precede the development of the metabolic syndrome in human adults.

Adrenal bez kalınlığının multi-dedektörlü bilgisayarlı tomografi ile değerlendirilmesi [Evaluation of the thickness of the adrenal glands with multi-detector computed tomography

Objectives: The aim of this study was to investigate adrenal gland size, and whether there is a thickness difference between two sides of adrenal glands by multi- detector computed tomography, by which anatomic details can be evaluate better. Materials and methods: Totally, 100 patients, who do not have adrenal gland pathology and outer adrenal gland body, are analyzed retrospectively by computed tomography with 16 and 64 detectors in regards of bilateral adrenal gland thickness. Results: After measurements, it was found that the difference between both adrenal gland medial and lateral limb thickness was statistically significant (p< 0.001, p=0.035). But no significant difference was found between both adrenal gland bodies (p=0.611). Conclusions: It was observed that left adrenal gland was thicker than the right in regards of variety. Further studies are necessary to conduct comprehensive investigations in regards of standardization of adrenal gland thicknesses.

High-intensity exercise training produces morphological and biochemical changes in adrenal gland of mice.

The effects of training are dependent on complex, adaptive changes which are induced by acute physical exercise at different levels. In particular, evidence shows that the hypothalamus-pituitary-adrenocortical axis, as well as the sympatho-adrenomedullary system, is mainly involved in mediating the physiological effects of physical exercise. The aim of the present study was to investigate, through a morphological and biochemical approach, the effects of training on the adrenal gland of mice, following two different protocols consisting of either low- or high-intensity training. Mice were run daily on a motorised treadmill for 8 weeks, at a velocity corresponding to 60% (low-intensity exercise) or 90% (high-intensity exercise) of the maximal running velocity previously determined by an incremental exercise test. We found that physical exercise produced an increase in the adrenal gland size compared with the control (sedentary) mice. The increase was 31.04% for mice that underwent high-intensity exercise and 10.08% for mice that underwent low intensity exercise, and this appeared to be the result of an increase in the area of both the adrenal cortex and adrenal medulla. Morphological analysis of the adrenal cortex showed that both types of exercise produced an increase in cytoplasmic vacuoles in steroidogenic cells, appearing more abundant after high-intensity exercise. No change was found in the reticulate zone. In the adrenal medulla, despite the absence of morphological changes, immunohistochemistry for tyrosine hydroxylase, dopamine β-hydroxylase and phenyl-ethanolamine-N-methyltransferase demonstrated an increased immunopositivity for these cathecolamine-synthesizing enzymes after intense exercise. These results were confirmed by immunoblot accompanied by densitometric analysis.

Lack of Significant Metabolic Abnormalities in Mice with Liver-Specific Disruption of 11β-Hydroxysteroid Dehydrogenase Type 1

Glucocorticoids (GC) are implicated in the development of metabolic syndrome, and patients with GC excess share many clinical features, such as central obesity and glucose intolerance. In patients with obesity or type 2 diabetes, systemic GC concentrations seem to be invariably normal. Tissue GC concentrations determined by the hypothalamic-pituitary-adrenal (HPA) axis and local cortisol (corticosterone in mice) regeneration from cortisone (11-dehydrocorticosterone in mice) by the 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) enzyme, principally expressed in the liver. Transgenic mice have demonstrated the importance of 11β-HSD1 in mediating aspects of the metabolic syndrome, as well as HPA axis control. In order to address the primacy of hepatic 11β-HSD1 in regulating metabolism and the HPA axis, we have generated liver-specific 11β-HSD1 knockout (LKO) mice, assessed biomarkers of GC metabolism, and examined responses to high-fat feeding. LKO mice were able to regenerate cortisol from cortisone to 40% of control and had no discernible difference in a urinary metabolite marker of 11β-HSD1 activity. Although circulating corticosterone was unaltered, adrenal size was increased, indicative of chronic HPA stimulation. There was a mild improvement in glucose tolerance but with insulin sensitivity largely unaffected. Adiposity and body weight were unaffected as were aspects of hepatic lipid homeostasis, triglyceride accumulation, and serum lipids. Additionally, no changes in the expression of genes involved in glucose or lipid homeostasis were observed. Liver-specific deletion of 11β-HSD1 reduces corticosterone regeneration and may be important for setting aspects of HPA axis tone, without impacting upon urinary steroid metabolite profile. These discordant data have significant implications for the use of these biomarkers of 11β-HSD1 activity in clinical studies. The paucity of metabolic abnormalities in LKO points to important compensatory effects by HPA activation and to a crucial role of extrahepatic 11β-HSD1 expression, highlighting the contribution of cross talk between GC target tissues in determining metabolic phenotype.

Evolving adrenal insufficiency

Introduction:Tuberculosis is the most common cause of Addison's disease in India. The exact status of adrenal reserve in tuberculosis is still an enigma and recovery of adrenal function is unpredictable.Objective:We report a case with a pre-Addisonian state and unchanged adrenal size after 1 year treatment.Materials and Methods:A 31-year patient with adrenal tuberculosis was diagnosed and treated with anti tubercular drugs (ATDs) and steroid.Results:A 31-year male, presented with fever and weight loss for 3½ months with anorexia, nausea, hyperpigmentation of skin, and buccal mucosa and weakness with past h/o adequately treated pulmonary tuberculosis at 3 years of age. On examination, the patient was anemic. A non-tender, firm right (Rt.) submandibular lymphnode was palpable. Investigations revealed: High erythrocyte sedimentation rate (ESR), negative HIV, and sputum for acid fast bacilli (AFB). Initial cortisol was high but subsequently became low with negative short synacthin test (SST). Computed tomography showed bilateral (B/L) enlarged hypodense adrenal mass with inconclusive fine needle aspiration cytology (FNAC) and negative AFB culture. Rt. submandibular lymph node FNAC showed caseating granuloma. ATDs and steroids were started, the lymphadenopathy regressed and symptoms subsided. However, after 1 year of treatment steroid withdrawal failed and adrenal size remained the same.Conclusion:The adrenal has considerable capacity to regenerate during active infection and ultimately become normal or smaller in size. However, in the case reported here, they failed to regress. Reversal of adrenal function following ATD is a controversial issue. Some studies have shown normalization following therapy, while others have contradicted it similar to the finding in our case.

腎細胞癌，腎血管筋脂肪腫に合併した副腎Solitary fibrous tumorの1例

Solitary fibrous tumor (SFT) is a neoplasm of pleura and its occurrence in the retroperitoneal space is rare. We report a case of SFT of the adrenal gland associated with ipsilateral renal cell carcinoma (RCC) and angiomyolipoma (AML). A 48-year-old woman was referred to our hospital for a left renal AML. Computed tomography (CT) in our hospital showed a left adrenal mass (25 x 20 mm). Because the adrenal tumor was nonfunctioning, she was followed at outpatient clinic. Four years later, CT showed an increase in the left adrenal tumor size (42 x 30 mm) and a left RCC. Left adrenectomy and partial nephrectomy for RCC and AML were simultaneously performed. Histological examination revealed adrenal SFT and clear cell carcinoma and AML of the kidney. We present a brief review on histological characteristics of retroperitoneal SFT and its occurrence in the adrenal grand region.

High frequency of adrenal myelolipomas and testicular adrenal rest tumours in adult Norwegian patients with classical congenital adrenal hyperplasia because of 21-hydroxylase deficiency

Increased frequencies of adrenal tumours and testicular adrenal rest tumours (TART) have been reported in patients with 21-hydroxylase deficiency (21OHD). Patients, methods and design From a cross-sectional population-based study of 101 adult Norwegian patients with 21OHD, sixty-two participated in this study (23 men, 39 women; age range 18-75); thirty-two were salt wasting (SW) and 30 simple virilizing (SV); they were assessed with adrenal computed tomography (CT), testicular ultrasound and hormone measurement in the morning after overnight medication fast. Nine adrenal tumours were detected in seven (11%) patients (bilateral in 2); four were myelolipomas and one a phaeochromocytoma. Seventeen (27%) had normal adrenal size, whereas 36 (58%) had persisting hyperplasia, and seven (11%) adrenal hypoplasia. Abnormal adrenals were more common in SW than in SV. TART occurred exclusively in SW and was present in seven (57%) of these men. Testicular volumes were small compared with normative data. Morning ACTH and 17-hydroxyprogesterone levels correlated positively with adrenal dimensions and frequency of TART. In this unselected population of patients with classical 21OHD, we found high frequencies of adrenal tumours, particularly myelolipomas, and of hyperplasia and hypoplasia, and TART in SW. It is important that physicians are aware that benign adrenal and testicular tumours occur frequently in 21OHD. Furthermore, these findings may reflect inappropriate glucocorticoid therapy, making a case for the advancement of novel physiological treatment modalities.

Elective and Emergency Surgical Management of Adrenal Gland Tumors: 60 Cases (1999–2006)

Sixty-one adrenal gland tumors were surgically removed from 60 dogs. Fifty-two dogs underwent elective adrenalectomy and 8 dogs underwent emergency adrenalectomy for acute adrenal hemorrhage. Size of adrenal tumors ranged from 10 mm to 80 mm. Histopathology confirmed a diagnosis of adrenocortical tumor in 47 dogs, 26 of which were malignant. Pheochromocytoma was diagnosed in 11 dogs. Six dogs had tumor invasion of the caudal vena cava. Of the seven dogs that did not survive the perioperative period, four underwent emergency adrenalectomy. No dogs with tumor invasion of the caudal vena cava died perioperatively. Perioperative morality rates were 5.7% for dogs that underwent elective adrenalectomy and 50% for dogs that underwent emergency adrenalectomy for acute adrenal hemorrhage. Median survival time was 492 days for the 53 dogs that survived the perioperative period. Of the factors analyzed, only adrenal tumor size and the presence of acute adrenal hemorrhage had predictive values for perioperative mortality. Those dogs that survived the perioperative period had extended survival times of up to 1,590 days. The mortality rate associated with elective adrenalectomy in dogs may be lower than previously reported. Dogs with very large tumors or acute adrenal hemorrhage may have a more guarded prognosis.

Use of Computed Tomography Adrenal Gland Measurement for Differentiating ACTH Dependence from ACTH Independence in 64 Dogs with Hyperadenocorticism

The measurement of adrenal gland size on computed tomography (CT) scan has been proposed for the etiological diagnosis of hyperadrenocorticism (HAC) in dogs. Symmetric adrenal glands are considered to provide evidence for ACTH-dependent hyperadrenocorticism (ADHAC), whereas asymmetry suggests ACTH-independent hyperadrenocorticism (AIHAC). However, there are currently no validated criteria for such differentiation. The aim of this retrospective study was to compare various adrenal CT scan measurements and the derived ratios in ADHAC and AIHAC cases, and to validate criteria for distinguishing between these conditions in a large cohort of dogs. Sixty-four dogs with HAC (46 ADHAC, 18 AIHAC). Dogs with confirmed HAC and unequivocal characterization of its origin were included. Linear measurements of adrenal glands were made on both cross-sectional and reformatted images. An overlap was systematically observed between the AIHAC and ADHAC groups for all measurements tested. Overlaps also were observed for ratios tested. For the maximum adrenal diameter ratio derived from reformatted images (rADR), only 1/18 AIHAC dogs had a rADR within the range for ADHAC. For a threshold of 2.08, the 95% confidence intervals for estimated sensitivity and specificity extended from 0.815 to 1.000 and from 0.885 to 0.999, respectively, for AIHAC diagnosis. Measurements from cross-sectional or reformatted CT scans are of little use for determining the origin of HAC. However, rADR appears to distinguish accurately between ADHAC and AIHAC, with a rADR > 2.08 highly suggestive of AIHAC.

Does Adrenal Size Matter?

Does Adrenal Size Matter?

Adrenal gland length in euploid and trisomy 18 fetuses at 11–13 weeks

To establish a normal range for fetal adrenal gland length at 11-13 weeks' gestation and to investigate whether the length is altered in fetal trisomy 18. Fetal adrenal gland length was measured by three-dimensional ultrasound in fetuses at low risk of aneuploidies (n = 400) and another group at high risk, including 380 euploid fetuses and 41 with trisomy 18. The data of the low-risk group were used to establish a reference range of adrenal gland length with crown-rump length (CRL). In the high-risk group, adrenal gland length in the euploid and trisomy 18 groups was compared. In the low-risk group, fetal adrenal gland size increased exponentially with fetal CRL from a median of 2.3 mm at CRL of 45 mm to about 4.4 cm at CRL of 84 mm. In trisomy 18, the median adrenal gland length for CRL was significantly lower than the median in the low-risk group (-1.37 mm; interquartile range: - 1.67 to - 0.99 mm, p < 0.0001). In euploid fetuses, the adrenal gland size was not significantly from the low-risk group (p = 0.100). Trisomy 18 is associated with adrenal gland hypoplasia which is apparent at 11-13 weeks' gestation.

A CASE OF ADRENAL TUBERCULOSIS COMPLICATED WITH ACUTE EXACERBATION OF ADRENAL INSUFFICIENCY DURING THE INITIAL PHASE O F ANTI-TUBERCULOSIS THERAPY FOR PULMONARY TUBERCULOSI S

A 36-year-old male was admitted to our hospital because of adrenal insufficiency. About one month before admission, he was diagnosed as pulmonary tuberculosis and started anti-tuberculosis therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide. On the tenth day, general fatigue, abdominal pain, nausea and diarrhea developed, and laboratory examination showed hyponatremia [126 mEq/l]. Enhanced CT on admission revealed bilateral adrenal mass-like enlargement, and further examination showed high level of plasma ACTH, and low level of cortisol. These findings led to a diagnosis of adrenal insufficiency caused by adrenal tuberculosis. He was treated with hydrocortisone and his signs and symptoms rapidly improved. We suppose adrenal insufficiency became clinically apparent because rifampicin reduced half-life of serum cortisol. Interestingly we observed rapid increase and decrease in size of bilateral adrenal glands on CT scan during the course.

An X-traordinary stroke

In January, 2010, a 60-year-old non-smoking, white man with mild intellectual disability, presented with acuteonset diplopia and ataxic gait. There was no consanguinity or relevant family history. CT of the brain showed a left cerebellar infarct. Blood tests showed he had polycythaemia with haemoglobin of 220 g/L (normal range 130–170). Investigations to fi nd a cause for the polycythaemia showed that although his erythropoietin concentration was normal and JAK2 mutation screening negative, serum total testosterone concentration was high at 29·1 nmol/L (normal 550 nmol/L at 30 min or 60 min), high serum concentrations of 17-hydroxyprogesterone 66·9 nmol/L (<5 nmol/L) and of androstendione, 31·6 nmol/L (2·0–9·1). His urinary steroid profi le was consistent with 21-hydroxylase defi ciency. A diagnosis of congenital adrenal hyperplasia was made. Our patient’s polycythaemia was treated with regular venesection, and glucocorticoid therapy was initiated to decrease corticotropin concentrations. Adrenal size decreased substantially within weeks of glucocorticoid initiation. The importance of glucocorticoid therapy to prevent future adrenal crises and androgen excess was emphasised. He may need testosterone therapy to maintain virilisation in the future. In September, 2010 at last follow-up he was stable. Congenital adrenal hyperplasia is the most common cause of antenatal virilisation in females. 95% of cases are due to defi ciency of 21-hydroxylase, an enzyme necessary for the synthesis of cortisol. Low serum cortisol concentrations stimulate secretion of corticotropin, which leads to excess production of androgenic steroids. Treatment is with glucocorticoids to prevent adrenal crisis and to normalise corticotropin concentrations, preventing excess androgen production. Excessive use of glucocorticoids should be avoided, because it can lead to growth retardation and iatrogenic Cushing’s syndrome. Our patient’s congenital adrenal hyperplasia was untreated for decades, and the sustained high concentrations of corticotropin caused severe adrenal hyperplasia with increased androgen production. Androgen excess during growth resulted in his short stature because of premature closure of the epiphyses. Androgen excess leads to polycythaemia through stimulation of erythropoiesis. Although polycythaemia is a well-described risk factor for stroke, androgenic polycythaemia in congenital adrenal hyperplasia has been reported only rarely. Androgen excess should be considered as a cause for poly cythaemia. Our patient’s case highlights the harmful eff ects of unfettered androgen excess in untreated congenital adrenal hyper plasia, and is also an important reminder on the importance of a genital examination as a part of a complete physical examination.

Long-term Efficacy of Trilostane for Cushing's Syndrome due to Adrenocorticotropin-Independent Bilateral Macronodular Adrenocortical Hyperplasia

A 66-year-old man with Cushing's syndrome due to adrenocorticotropin-independent bilateral macronodular adrenocortical hyperplasia (AIMAH) was treated for 7 years with trilostane, a 3β-hydroxysteroid dehydrogenase inhibitor. Administration of trilostane reduced the serum cortisol level to around the upper limit of normal for 7 years, and symptoms of excessive glucocorticoid production (such as moon face and obesity) were gradually improved. On the other hand, the size of both adrenal glands gradually increased despite treatment with trilostane. Though trilostane therapy could not prevent adrenal growth, it did suppress cortisol secretion over the long term, so it might be a reasonable option for AIMAH in addition to adrenalectomy.

Ultrasonographic Adrenal Gland Measurements in Clinically Normal Small Breed Dogs and Comparison with Pituitary-Dependent Hyperadrenocorticism

Ultrasonography is a sensitive and specific screening method for assessing the adrenal glands. The upper limit of the normal adrenal gland width is used as 7.5 mm. It is not known if adrenal gland width remains consistent with body weight. A reliable criterion of adrenal gland width in small breed dogs should be established. Small breed dogs with body weights of less than 10 kg were divided into two groups: 189 normal dogs and 22 dogs with pituitary-dependent hyperadrenocorticism (PDH). A retrospective study was conducted on dogs seen between January 1, 2006, and February 10, 2008. One hundred eighty-nine dogs of 14 different small breeds were enrolled in the normal adrenal gland group; the median gland width was 4.20 mm. Twenty-two dogs were in the PDH group; the median gland width was 6.30 mm. The cut-off value between normal adrenal glands and PDH was 6.0 mm. This figure gave a sensitivity and specificity of 75 and 94%, respectively, for detecting PDH. The adrenal gland appeared as a peanut shape with homogeneous hypoechoic parenchyma in normal dogs and in most dogs with PDH as well. This study was performed in a large population of small breed dogs and suggests that the normal adrenal gland size in small breed dogs is smaller than previously reported. We believe that a cut-off of 6.0 mm may be used as the criterion for differentiating a normal adrenal gland from adrenal hyperplasia.

High-intensity exercise training produces morphological and biochemical changes in adrenal gland of mice

The effects of training are dependent on complex, adaptive changes which are induced by acute physical exercise at different levels. In particular, evidence shows that the hypothalamus-pituitary-adrenocortical axis, as well as the sympathoadrenomedullary system are mainly involved in mediating the physiological effects of physical exercise. The aim of the present study was to investigate, through a morphological and biochemical approach, the effects of training on the adrenal gland of mice, following two different protocols consisting of either low- or high-intensity training. Mice were run daily on a motorized treadmill for 8 weeks, at a velocity corresponding to 60% (low-intensity exercise) or 90% (high-intensity exercise) of the maximal running velocity previously determined by an incremental exercise test. We found that physical exercise produced an increase in the adrenal gland size compared with the control (sedentary) mice. Such increase was 31.04% for mice that underwent high-intensity exercise and 10.08% for mice that underwent low intensity exercise, and this appeared to be the result of an increase in the size of both the adrenal cortex and adrenal medulla. Morphological analysis of the adrenal cortex showed that both types of exercise produced an increase in cytoplasmic vacuoles in steroidogenic cells, appearing more abundant after high-intensity exercise. No change was found in the reticulate zone. In the adrenal medulla, despite the absence of morphological changes, immunohistochemistry for tyrosine hydroxylase, dopamine ?-hydroxylase and phenyl-ethanolamine-N-methyltransferase demonstrated an increased immunopositivity for these cathecolamine-synthesizing enzymes after intense exercise. These results were confirmed by immunoblot accompanied by densitometric analysis.

Diagnostic Value of I‐131 NP‐59 SPECT/CT Scintigraphy in Patients with Subclinical or Atypical Features of Primary Aldosteronism

Accumulating evidence has shown the adverse effect of long-term hyperaldosteronism on cardiovascular morbidity that is independent of blood pressure. However, the diagnosis of primary aldosteronism (PA) remains a challenge for patients who present with subtle or atypical features or have chronic kidney disease (CKD). SPECT/CT has proven valuable in the diagnosis of a number of conditions. The aim of this study was to determine the usefulness of I-131 NP-59 SPECT/CT in patients with atypical presentations of PA and in those with CKD. The records of 15 patients with PA were retrospectively analyzed. NP-59 SPECT/CT was able to identify adrenal lesion(s) in CKD patients with suspected PA. Patients using NP-59 SPECT/CT imaging, compared with those not performing this procedure, significantly featured nearly normal serum potassium levels, normal aldosterone-renin ratio, and smaller adrenal size on CT and pathological examination and tended to feature stage 1 hypertension and non-suppressed plasma renin activity. These findings show that noninvasive NP-59 SPECT/CT is a useful tool for diagnosis in patients with subclinical or atypical features of PA and those with CKD.

Laparo-Endoscopic Single Site Anatomical Retroperitoneoscopic Adrenalectomy Using Conventional Instruments: Initial Experience and Short-Term Outcome

To our knowledge we present the initial experience with and the short-term outcome of laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy using conventional instruments. Between June 2009 and April 2010, 25 patients underwent laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy. A TriPort™ Access System was inserted through a 2.5 to 3.0 cm transverse skin incision below the tip of the 12th rib. Adrenalectomy was done using a 5 mm 30-degree laparoscopic camera and 2 conventional laparoscopic instruments. After Gerota's fascia was incised we explored the first dissection plane between the perirenal fat and the anterior renal fascia at the superomedial side of the kidney. The adrenal gland was identified at the initial stage of the operation. Laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy was successfully accomplished in 23 patients. An additional 5 mm port was required in 1 of the 2 unsuccessful cases and in the other it was necessary to convert to standard anatomical retroperitoneoscopic adrenalectomy. Median incision length was 3.0 cm, median operative time was 55 minutes and median estimated blood loss was 15 ml. No major intraoperative complications occurred. In the initial 10 cases median operative time was significantly longer (62 vs 50 minutes) and median blood loss was significantly higher (75 vs 10, each p <0.001) than in the subsequent 15. In 3 cases pheochromocytoma was successfully excised without undesirable hemodynamic oscillation. Postoperative complications developed in 2 patients, including angina and contralateral atelectasis in 1 each. In properly selected patients laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy with conventional instruments is feasible, safe and effective, causes minimal morbidity and results in excellent cosmesis.

Stress Vulnerability during Adolescent Development in Rats

Adolescent development is proposed to represent a time of increased susceptibility to stress. During adolescence, the brain demonstrates a high level of plasticity and can be positively or negatively affected by the environment. This study tests the hypothesis that adolescent development is a stage of enhanced vulnerability to chronic stress. Male Sprague-Dawley rats were exposed to our 14-d chronic variable stress (CVS) paradigm at three developmental stages: 1) early adolescence (35 d; age at initiation of CVS); 2) late adolescence (50 d); or 3) adulthood (80 d). We examined the effects of CVS on the following: 1) depression-like behavior; 2) somatic indices; 3) hypothalamic-pituitary-adrenal (HPA) axis activity; and 4) neuropeptide expression in the hypothalamus. Results show, regardless of age, CVS exposure: 1) decreased body weight; 2) increased adrenal size; 3) decreased fat weight; and 4) increased HPA response to stress. The somatic effects of CVS were exaggerated in late adolescent animals, and late adolescent animals were the only group where CVS decreased oxytocin expression and increased basal corticosterone. In response to CVS, adult animals increased immobility during the forced-swim test while early and late adolescent animals were resistant to the effects of chronic stress on depression-like behavior. Results show that adolescent animals were protected from the effect of chronic stress on depression-like behavior while late adolescent animals were more susceptible to the somatic, HPA axis, and neuropeptide effects of chronic stress. Thus, adolescent development is a unique window of vulnerabilities and protections to the effects of chronic stress.