Unilateral Laparoscopic Adrenalectomy Research Articles

PROSPECTIVE APPRAISAL ON THE PREVALENCE OF PRIMARY ALDOSTERONISM AND ITS SUTYPES IN HYPERTENSIVE PATIENTS PRESENTING WITH ATRIAL FLUTTER OR FIBRILLATION

Objective: Excess aldosterone has been suggested to favour and/or cause atrial fibrillation (AF), particularly in the patients with arterial hypertension, but the relationship between AF and primary aldosteronism (PA) remains uncertain. Hence, we tested the hypothesis that AF is one of the presenting signs of unrecognized PA, and investigated the prevalence of PA and its subtypes in hypertensive patients presenting with lone AF. Design and method: Consecutive patients with an unambiguous diagnosis of arterial hypertension presenting with ECG-confirmed AF and no obvious causes of the arrhythmia were recruited and submitted to the screening and subtyping for PA according to the Endocrine Society PA current guidelines, including measurement of plasma renin activity and aldosterone levels after appropriate pharmacological preparation, and adrenal vein sampling (Funder J. JCEM 2016). The diagnosis of aldosterone-producing adenoma followed the four corner criteria, which imply cure of PA after adrenalectomy (Rossi GP. JACC 2006). Results: From 2015 to 2017, 296 patients (age 76 ± 12 years; 48/52 F/M, %) were recruited in three ESH centers of Excellence for arterial hypertension in Italy (Padua, Brescia and Rome). Fifty-five patients, who met the inclusion criteria and had no exclusion criteria, underwent the entire diagnostic work-up for PA. This allowed to ascertain that the overall prevalence of PA was 34.5%, 42% of the cases being accounted for by aldosterone-producing adenoma and the rest by bilateral forms. Conclusions: By providing compelling evidence for a high prevalence of PA in hypertensive patients presenting with the so-called “lone” AF, these results can lead to changing clinical practice in the management of these patients in that they indicate the need to carefully searching for PA and undertaking subtyping with the aim of pinpointing those who can be cured with unilateral laparoscopic adrenalectomy.

MANAGEMENT OF ENDOCRINE DISEASE: Diagnosis and management of primary aldosteronism: the Endocrine Society guideline 2016 revisited.

The syndrome of primary aldosteronism (PA) is characterized by hypertension with excessive, autonomous aldosterone production and is usually caused by either a unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia. The diagnostic workup of PA is a sequence of three phases comprising screening tests, confirmatory tests and the differentiation of unilateral from bilateral forms. The latter step is necessary to determine the optimal treatment approach of unilateral laparoscopic adrenalectomy (for patients with unilateral PA) or medical treatment with a mineralocorticoid receptor antagonist (for patients with bilateral PA). Since the publication of the revised Endocrine Society guideline 2016, a number of key studies have been published. They challenge the recommendations of the guideline in some areas and confirm current practice in others. Herein, we present the recent developments and current approaches to the medical management of PA.

Contralateral adrenal width predicts the duration of prolonged post-surgical steroid replacement for subclinical Cushing syndrome.

To identify pre-treatment factors affecting the duration of post-surgical steroid replacement in patients undergoing adrenalectomy for subclinical Cushing syndrome. The present retrospective analysis included 64 patients who underwent unilateral laparoscopic adrenalectomy for subclinical Cushing syndrome. Adrenal tumor and contralateral adrenal sizes together with various clinical factors were studied in association with the duration of post-surgical steroid replacement. Adrenal tumor and contralateral adrenal size were measured at the level of the maximum transverse plane of the adrenal glands using computed tomography scan or magnetic resonance imaging. Cox's proportional hazards model was used for the statistical analysis. All 64 patients were treated with post-surgical steroid replacement after adrenalectomy. The median duration of the steroid treatment was 6 months. When assessing the duration of post-surgical steroid replacement, contralateral adrenal volume <0.745 cm3 , contralateral adrenal width <6.15 mm and serum cortisol after a 1-mg dexamethasone suppression test >2.65 μg/dL were significant predictors of prolonged post-surgical steroid treatment on univariate analysis. On multivariate analysis, contralateral adrenal width <6.15 mm was the only independent predictive factor for the prolonged post-surgical steroid replacement. Contralateral adrenal width seems to represent a significant predictive factor for the duration of post-surgical steroid replacement in subclinical Cushing syndrome patients. Pre-surgical assessment of image findings might help clinicians determine the total duration of steroid therapy after adrenalectomy.

Adrenal Vein Sampling Is the Preferred Method to Select Patients With Primary Aldosteronism for Adrenalectomy: Pro Side of the Argument.

Hyperaldosteronism, caused by an aldosterone-producing adenoma (APA) or much less commonly unilateral adrenal hyperplasia, can be cured or improved in >95% of patients by unilateral laparoscopic adrenalectomy. Approximately 50% of these patients have a complete clinical remission, with blood pressure returning to normal levels without the need for antihypertensives. In the remaining ≈50%, blood pressure levels commonly fall but not into the normal range, despite biochemical cure: such patients require continuing but usually lower levels of antihypertensive therapy. The persistent hypertension is commonly attributed to vascular damage or underlying primary hypertension. APA/unilateral adrenal hyperplasia together account for ≈5% of hypertension,1 with the remainder of primary aldosteronism (PA) caused by bilateral adrenal hyperplasia. The prevalence of bilateral adrenal hyperplasia, commonly a less florid form of PA, seems currently to reflect the disparate cutoffs used. Reported levels are equal to or less than those of unilateral disease if strict cutoffs in screening and confirmatory testing are used, and approximately double when more relaxed cutoffs are in place. Such patients are not treated by adrenalectomy, except in a handful of cases of fulminant familial hypertension type III, but with mineralocorticoid receptor antagonists, amiloride, and other antihypertensive agents as required. A large, recent study has shown that a markedly elevated aldosterone-to-renin ratio accurately identified patients with an APA but not its location.2 In most jurisdictions, the advantages of laparoscopic adrenalectomy for unilateral disease are well recognized. These include total cure in half the patients lateralized who are relieved of the burden and cost of lifetime medication and lower levels of medication for blood pressure in the remainder. In addition, patients note a marked improvement in well-being and quality of life. For this reason, adrenal venous sampling (AVS) is recommended3,4 for confirmed PA patients, with some exceptions. Rarely are patients …

Hemodynamic instability during surgery for pheochromocytoma: comparing the transperitoneal and retroperitoneal approach in a multicenter analysis of 341 patients

Intraoperative hemodynamic instability is a major challenge during adrenalectomy for pheochromocytoma. Typically, pheochromocytoma is performed laparoscopically either through the retroperitoneal or transperitoneal approach. We aimed to determine if the operative approach affects intraoperative hemodynamic instability during surgery for pheochromocytoma in a large multicenter multicenter cohort. Retrospective, multicenter analysis of consecutive patients with pheochromocytoma who underwent total unilateral laparoscopic adrenalectomy without conversion were included. Statistical analysis was performed using established intraoperative criteria for intraoperative hemodynamic instability: 1) systolic blood pressure >160 mm Hg; 2) systolic blood pressure > 200 mm Hg; 3) mean arterial pressure <60 mm Hg; 4) systolic blood pressure >160 mm Hg + mean arterial pressure <60 mm Hg; and 5) systolic blood pressure >200 mm Hg + mean arterial pressure <60 mm Hg; and 6) intravenous vasopressor + vasodilator. In total, 341 patients met the inclusion criteria, 101 (29.6%) underwent retroperitoneal adrenalectomy and 240 (70.4%) transperitoneal adrenalectomy. Multivariate analysis showed that retroperitoneal adrenalectomy carries greater risk for mean arterial pressure <60 mm Hg (odds ratio 6.255, confidence interval 1.134-34.235, P = .035) compared with transperitoneal adrenalectomy. Overall and cardiovascular morbidity rates were comparable between the 2 approaches. The medical center was a significant independent influencing factor for all 6 intraoperative hemodynamic instability definitions. Variability in institutional management of pheochromocytoma intraoperatively has significant impact on all 6 intraoperative hemodynamic instability definitions. Standardization of anesthesia should be considered to reduce this variability.

Diagnosis and management of primary aldosteronism.

Primary aldosteronism (PA) is the most common form of secondary hypertension (HTN), with an estimated prevalence of 4% of hypertensive patients in primary care and around 10% of referred patients. Patients with PA have higher cardiovascular morbidity and mortality than age- and sex-matched patients with essential HTN and the same degree of blood pressure elevation. PA is characterized by an autonomous aldosterone production causing sodium retention, plasma renin supression, HTN, cardiovascular damage, and increased potassium excretion, leading to variable degrees of hypokalemia. Aldosterone-producing adenomas (APAs) account for around 40% and idiopathic hyperaldosteronism for around 60% of PA cases. The aldosterone-to-renin ratio is the most sensitive screening test for PA. There are several confirmatory tests and the current literature does not identify a "gold standard" confirmatory test for PA. In our institution, we recommend starting case confirmation with the furosemide test. After case confirmation, all patients with PA should undergo adrenal CT as the initial study in subtype testing to exclude adrenocortical carcinoma. Bilateral adrenal vein sampling (AVS) is the gold standard method to define the PA subtype, but it is not indicated in all cases. An experienced radiologist must perform AVS. Unilateral laparoscopic adrenalectomy is the preferential treatment for patients with APAs, and bilateral hyperplasia should be treated with mineralocorticoid antagonist (spironolactone or eplerenone). Cardiovascular morbidity caused by aldosterone excess can be decreased by either unilateral adrenalectomy or mineralocorticoid antagonist. In this review, we address the most relevant issues regarding PA screening, case confirmation, subtype classification, and treatment.

Development of novel nomograms to predict renal functional outcomes after laparoscopic adrenalectomy in patients with primary aldosteronism.

Most patients with primary aldosteronism (PA) show a significant decrease in kidney function after surgery. Glomerular hyperfiltration peculiar to PA can mask mild renal failure before surgery. The aim of this retrospective study was to investigate postoperative renal functional outcomes in PA patients from different viewpoints and to develop novel nomograms that can predict renal functional outcomes in PA patients after surgery. 130 Japanese PA patients treated by unilateral laparoscopic adrenalectomy were retrospectively surveyed. Pre- and postoperative changes of estimated glomerular filtration rates (eGFRs) and the distribution of eGFR classification were compared. Furthermore, predictors of the following renal functional outcomes were investigated: (I) the percentage decrease >25% in eGFR and (II) the presence of new-onset eGFR <45ml/min/1.73m2. Finally, two nomograms that predicted postoperative renal functional outcomes were developed and internally validated. At 6months, the average decrease in eGFR was 16.7mL/min/1.73m2 (corresponding percent decrease: 19.7%). Upstaging of eGFR classification was observed in 54.6% of patients. Age, potassium, plasma aldosterone concentration, and initial eGFR were incorporated into a nomogram predicting a >25% postoperative decrease in eGFR. Duration of hypertension and initial eGFR were incorporated into a nomogram predicting new-onset eGFR <45ml/min/1.73m2. The value of the area under the receiver operating characteristics curve for each nomogram was 0.82 and 0.74, respectively. The first nomograms that can predict postoperative renal outcomes in PA patients were developed. They will help clinicians calculate the probability of renal dysfunction in PA patients after laparoscopic adrenalectomy.

Accuracy of adrenal imaging and adrenal venous sampling in diagnosing unilateral primary aldosteronism.

The correct differentiation between unilateral and bilateral adrenal involvement in patients with primary aldosteronism (PA) is of utmost importance to justify surgical treatment. The aim of this study was to determine the accuracy of adrenal imaging compared to adrenal venous sampling (AVS), histopathology and postoperative outcome. The data of all patients with unequivocal AVS who underwent unilateral laparoscopic adrenalectomy for primary aldosteronism between May 2004 and April 2015 were entered in this retrospective study. We compared computed tomography (CT) and magnetic resonance imaging (MRI) results with corresponding AVS data, histopathology findings and postoperative outcome. A total of 175 patients underwent unilateral laparoscopic adrenalectomy for primary aldosteronism. AVS was successful in 152 patients and postoperative outcome available in 148 patients. Despite unilateral disease according to AVS results, bilateral normal glands were seen in 15 MRI (17·2%) and 7 CT scans (8·5%), respectively. Unilateral enlargement of the nonhypersecreting adrenal gland was found in three MRI (3·5%) and 10 CT scans (12·2%) of patients who showed aldosterone hypersecretion deriving from the contralateral gland. Fifteen MRI (17·2%) and 18 CT scans (22·0%) revealed bilateral adrenal pathology despite unilateral aldosterone hypersecretion. The accuracy of CT and magnetic resonance imaging in predicting unilateral disease is poor. AVS appears to be an essential diagnostic step to identify those patients who may benefit from unilateral adrenalectomy.

Clinical Benefits of Unilateral Adrenalectomy in Patients with Subclinical Hypercortisolism Due to Adrenal Incidentaloma: Results from a Single Center.

This study was designed to evaluate the results of unilateral laparoscopic adrenalectomy in patients with subclinical hypercortisolism (SH) due to adrenal incidentaloma (AI) concerning the main cardiometabolic disorders. We have studied between January 2000 to December 2015, 645 patients with AI (283 males and 362 females; mean age 61.9±10years) and we found 70 patients with SH (27 males and 43 females; mean age 61.9±8.4years). Twenty-six (37%) SH patients (6 males and 20 females; mean age 58.7±7.1years) underwent unilateral laparoscopic adrenalectomy, whereas 44 SH patients (21 males and 23 females; mean age 63.9±9.9years) performed a conservative treatment. All SH patients were evaluated at diagnosis and after follow-up (mean 12months; range 9-15months). In only SH patients undergoing unilateral adrenalectomy we found a statistical significant reduction of the arterial hypertension and metabolic syndrome (p<0.05, respectively). In particular we observed a reduction of 24-h systolic blood pressure and "non-dipper" pattern (p<0.05, respectively) evaluated with ambulatory blood pressure monitoring (ABPM). Our study confirm the high prevalence of SH in AI, and the unilateral laparoscopic adrenalectomy seemed to have a beneficial effect on some cardiometabolic disorders.

Long-term Outcomes of Unilateral Adrenalectomy in Patients with Dominant-side Adrenal Hyperplasia

ABSTRACT Introduction Usual treatment for patients with aldosterone-producing adrenal adenoma is adrenalectomy, whereas adrenal hyperplasia is generally treated medically. Selective adrenal venous sampling (AVS) has been adopted to differentiate between adenoma and hyperplasia. A previous ratio used in our institution for the diagnosis of adenoma proved to be too low. As a result, a disproportionate number of patients with a preoperative diagnosis of adenoma were operated and subsequently found to have hyperplasia. Materials and methods This prospective study evaluated the long-term outcomes of unilateral laparoscopic adrenalectomy in the setting of lateralizing aldosterone hypersecretion caused by adrenal hyperplasia. Results Twelve patients with unilateral excess aldosterone production due to hyperplasia underwent dominant side adrenalectomy. Long-term follow-up (mean 12 years) of these patients showed that blood pressure decreased from a mean of 163.4 ± 17.5/100 to 131.5 ± 9.7/80 mm Hg (p &lt; 0.05), and the number of antihypertensive drugs decreased from 4.3 ± 0.7 to 2.2 ± 0.9 (p &lt; 0.05). Mean potassium level increased from 3.7 to 4.2 mEq/L and the plasma aldosterone level decreased from 26.5 to 10.1 ng/dL. Conclusion Dominant side adrenalectomy in patients with primary aldosteronism (PA) due to hyperplasia results in long-term clinical improvement. This procedure should be considered in selected patients with lateralization confirmed by venous sampling. How to cite this article Paran H, Elad G, Benchetrit S, Griton I, Haas I, Yaslowitz O, Shmulevsky P. Long-term Outcomes of Unilateral Adrenalectomy in Patients with Dominant-side Adrenal Hyperplasia. World J Endoc Surg 2017;9(2):37-40.

Pathogenetic forms of primary hyperaldosteronism: the analysis of clinical series of patients

Frequency of different clinical variants of primary hyperaldosteronism (PHA) has a particular interest for modern endocrinology because paradigm in understanding the pathogenesis of disease were changed.Purpose. The aim of the study was to establish the frequency of different clinical variants of PHA on the cohort of patients treated in Ukrainian Scientific and Practical Center of Endocrine Surgery within period of 1996–2014 years.Materials and methods. Results of diagnosis and treatment of 474 patients, who underwent surgical and therapeutic procedures, were retrospectively studied. All patients were investigated by screening of serum potassium, aldosteron-renin ratio, confirmation tests, multi-spiral computed tomography. Selective adrenal vein sampling was performed in 63 cases.Results and discussion. Analysis of PHA structure demonstrated the following distribution of forms: idiopathic adrenal hyperplasia – 235 (49.6%), aldosteron-producing adenoma – 195 (41.1%), primary (unilateral) adrenal hyperplasia – 36 (7.6%), familial forms of PHA – 6 (1.3%) (incl. GRA – 4, FH II – 2), adrenocortical carcinoma – 2 (0.4%). 255 patients were operated by unilateral laparoscopic adrenalectomy. Among 219 patients from the group of conservative treatment of PHA glucocorticoid-remediable aldosteronism (GRA) was suspected in у 22 patients and have been confirmed by ex-uvantibus treatment with dexamethasone in 4 patients. The rest of patients received treatment by antagonists of mineralocorticoid receptors.Conclusions. The first in Ukraine analysis of modern distribution clinical variants of PHA has demonstrated variability of disease with predomination of idiopathic bilateral adrenal hyperplasia and gradually decreasing the share of aldosteron- producing adenoma. Accurate diagnosis of specific form of primary hyperaldosteronism allows choosing adequate mode of therapy.

Hypertension Cure Following Laparoscopic Adrenalectomy for Hyperaldosteronism is not Universal: Trends Over Two Decades.

Laparoscopic adrenalectomy has been established as a standard surgical method for unilateral primary aldosteronism. Meanwhile, the background characteristics of the patients undergoing adrenalectomy have changed over the last 20years. The aim of this study was to investigate the changes in hypertension cure rates after laparoscopic adrenalectomy during the last two decades. This retrospective clinical study included 176 patients who underwent unilateral laparoscopic adrenalectomy for primary aldosteronism from 1995 to 2015. The patients were divided into two groups by decade. The patients' baseline characteristics and the hypertension cure rates were compared between the two groups. Additionally, the values were re-examined based on predictive model predicting postoperative hypertension cure. The hypertension cure rate decreased significantly from 51.8 to 31.1%. The following variables were significantly different between the two groups: age, sex, body mass index, history of diabetes mellitus, preoperative systolic and diastolic blood pressures, potassium level, and plasma renin activity. This study showed that the number of patients with unfavorable conditions for hypertension cure after adrenalectomy has recently increased. The treatment goal for primary aldosteronism is not only to cure the hypertension but also to prevent organ disorders due to inappropriate aldosterone levels. Therefore, we recommend laparoscopic adrenalectomy for unilateral primary aldosteronism, even if hypertension is not always cured postoperatively. However, clinicians need to fully explain the postoperative hypertension outcomes to primary aldosteronism patients.

Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma.

The optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes. We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP)>200, SBP<80, SBP<80 and>200, pulse>120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support. We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35% (n=18) of patients, and non-selective blockade with phenoxybenzamine was performed in 65% (n=34) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBP<80 (67%) than those blocked with phenoxybenzamine (35%) (p=0.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (p=0.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p=0.02). Hospital stay and complication rates were similar. Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications.

Laparoscopic Adrenalectomy versus Open Adrenalectomy for Benign Adrenal Tumours: Results from a Prospective Comparative Study

Objective: The purpose of this study is to compare the operative and postoperative outcomes of laparoscopic adrenalectomy (LA) with open adrenalectomy (OA) for benign adrenal lesions less than 6 cm in size. Patients and methods: From March 2011, to January 2015, patients with adrenal tumours were allocated to either unilateral laparoscopic or open adrenalectomy. Patients with adrenal masses >6 cm, suspected adrenal malignancies, and adrenal metastasis were excluded. Demographic data, operative findings, operative complications, postoperative complications, and duration of hospital stay were recorded and compared in both groups. Results: Two groups of patients (18 in each group) were allocated in this study. Both groups were statistically similar regarding age, gender, body mass index (BMI), and American Society of Anesthesiologists (ASA) score. Two patients in the laparoscopic group were converted to open resection. The mean operative time in the laparoscopic group was significantly higher. However, the mean operative blood loss, need for analgesics, time of passing flatus after surgery, the duration of hospital stay were significantly lower in the laparoscopic group. Postoperative complications, hemodynamic stability and need for blood transfusion showed no statistical difference in both groups. Conclusions: Laparoscopic adrenalectomy is a safe operative procedure offering faster recovery, and shorter hospital stay. Hence, we recommend laparoscopic adrenalectomy as the first line treatment for benign adrenal masses less than 6 cm in size.

The importance of postoperative control: adrenal insufficiency after unilateral adrenalectomy for Conn’s syndrome. A case study

According to the current guidelines of the Polish Society of Hypertension on the management of primary aldosteronism (PA) associated with aldosterone-producing adenoma, the treatment of choice is unilateral laparoscopic adrenalectomy. Isolated deficiency of aldosterone after adrenalectomy for Conn’s syndrome is rare. The literature finds few reports on postoperative hypoaldosteronism requiring mineralocorticoid replacement. In this case study we present a patient who developed postoperative hypoaldosteronism.

Unmasked chronic renal function deterioration after unilateral adrenalectomy in patients with primary aldosteronism

We report 2 cases of chronic estimated glomerular filtration rate (eGFR) decline after unilateral adrenalectomy due to primary aldosteronism. The patients were diagnosed with unilateral adrenal cortical adenoma releasing aldosterone. Two patients were examined for hypertension and hypokalemia. Unilateral laparoscopic adrenalectomy was performed in both cases, and pathology confirmed adrenal cortical adenoma. After adrenalectomy, hypertension and hypokalemia improved to within normal range. However, the eGFR decreased postoperatively, and abdominal computed tomography scan showed decreased kidney size compared to previous images. Kidney biopsy was performed to delineate the exact cause of renal function deterioration and revealed hypertensive changes with chronic interstitial changes, indicating that glomerular hyperfiltration with aldosterone excess masked renal function damage. Physicians have to consider the probability of postadrenalectomy eGFR decline related to chronic hypertensive change.

Long-term outcome after adrenalectomy for incidentally diagnosed subclinical cortisol-secreting adenomas

The management of subclinical cortisol-secreting adenomas (SCSAs) is controversial, and available evidence to assess the superiority of an operative versus a nonoperative approach is lacking. The aim of this work was to report the postoperative results and the long-term outcomes for patients with incidentally diagnosed SCSAs and to compare the results with those of patients who underwent an operation for cortisol-secreting adenomas (CSAs). From 1994-2011, 107 consecutive patients underwent laparoscopic unilateral adrenalectomy for either an SCSA (n=39) or a CSA (n=68). Preoperatively, all patients underwent standardized clinical, hormonal, and imaging assessments. Patients were followed up for ≥2years with serial assessments of body weight, blood pressure, and glycated hemoglobin, HbA1c. Operative resection of SCSAs and CSAs did not significantly differ regarding operative time, conversion rate, overall operative and medical morbidity, and duration of stay. For SCSAs, the comparison between preoperative status and 2-year assessment showed a median weight loss of 6% (P<.001), a decrease in the median HbA1c of 15% (P<.001), and an improvement or normalization of blood pressure in 50% of the patients. The same significant beneficial metabolic effects of the operation with even greater improvement were observed in patients with CSAs. Laparoscopic unilateral adrenalectomy for SCSA is associated with low morbidity, no mortality, and significant improvement of various aspects of metabolic syndrome. Until additional evidence from prospective randomized controlled studies is obtained, laparoscopic unilateral adrenalectomy should be considered a valid option in the care of patients with SCSA.

Right Laparoscopic Adrenalectomy in a Bitch

Background: The medical procedure of Laparoscopic adrenalectomy is common in human medicine; however, this is not true in veterinary medicine, where it isperformed rarely. The current treatment of choice for adrenal neoplasms is total adrenalectomy, unless there is a pre-operativediagnosis of metastasis that precludes surgery. The laparoscopic approach option becomes an interesting alternative because, through this technique,it has shown good results. In this report, we demonstrate the experience of a case in which we performed unilateral laparoscopic right adrenalectomy, without caudalvena cava invasion, in a dogsuffering from hyperadrenocorticism caused by adrenocortical carcinoma.Case: A 9-year-old beagle bitch, 12 kg in weight, showedpolyphagia, polydipsia, polyuria, pendular abdomen, thin and dark skin, lumbar alopecic areas and lethargy. The team carried out Complete Blood Count (CBC), blood chemistry (liver and renal functions) and urine sampling by cystocentesis for urinalysis and bacterial culture. All exams had normal results, except for ALP, which reached levels higher than 150 UIL-1. On abdominal radiographic examination, we noted mild adrenal enlargement, and by ultrasonography, it was possible to identify adrenal asymmetry and right adrenal enlargement (2.8x2x2.15 cm) in relation to the left gland (2x1x1.5 cm). As a treatment for adrenal neoplasm-dependent HAC,we recommended the execution of total right adrenalectomy execution. The videosurgery used four accesses arranged in the right hypogastric region; the diameters were 10 (two), 5, and 3mm. The adrenal gland was carefully dissected with the aid of laparoscopic forceps; during the intraoperative period, there was a small laceration of the abdominal phrenic vein that resulted in bleeding, which was overcome with two titanium clips. The dog had an excellent recovery, and the teamdischarged it 48 h after the procedure. The signs of hyperadrenocorticism disappeared about two weeks after surgery. One year after having the procedure, the animal remainswell and has no signs of tumor recurrence or Cushing’s syndrome.Discussion: The choice laparoscopic approach provided less invasiveness in surgical access, reduced animal convalescence, and provided image magnifcation for the more accurate dissection of the adrenal gland. Some reports that middle-aged to older bitches were the most predisposed to present adrenal neoplasm-dependent HAC, and generally, in unilateral form, characteristics which are presented in this report. Among the clinical signs and observed in this report, are polydipsia, polyphagia, tachypnea, alopecia, and skin hyperpigmentation. That recommended the low-dose dexamethasone suppression test to diagnose Cushing’s syndrome and the endogenous ACTH test to distinguish hypophysary from adrenocorticotrophic HAC. The same tests were performed in the case reported here, as these are also important to establish the fnal diagnosisand refer the total adrenalectomy realization. In the current case report, access to the right hypogastric region using four videosurgery portals provided good surgical access. Towards the hospital convalescence time, the animal was discharged early, just 48 h post-operatively; remission of HAC clinical signs occurredwithin three weeks, and the survival alreadyreached 12 months.To the best of the authors’ knowledge, this is the frst successful case of total right adrenalectomy without caudal vena cava invasion via the laparoscopic route as treatment for adrenocortical carcinoma in the national literature.Keywords: adrenal gland, neoplasm, videosurgery, dogs.

Preoperative risk factors of hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma.

Adrenalectomy for pheochromocytoma is considered to be a challenging procedure because of the risk of hemodynamic instability (HI), which is poorly defined and unpredictable. The objective of this retrospective study from a prospectively maintained database was to determine the predictive factors for perioperative HI, which is defined as a morbidity-related variable, in patients undergoing unilateral laparoscopic adrenalectomy (LA) for pheochromocytoma. A total of 149 patients with unilateral pheochromocytoma undergoing LA were included. First, HI was defined using independent hemodynamic variables associated with perioperative morbidity. Next, a multivariable logistic regression analysis was performed to determine the independent preoperative risk factors for HI. There was no postoperative mortality, and the overall morbidity rate was 10.7%. The use of a cumulative dose of norepinephrine >5mg was the only independent hemodynamic predictive factor for postoperative complications; thus, this variable was used to define HI. A multivariate analysis revealed that a symptomatic high preoperative blood pressure (p=0.003) and a ten-fold increase in urinary metanephrine and/or normetanephrine levels (p<0.0001) were significant predictors of HI. When no predictive factors were present, the risk of HI and the postoperative morbidity were 1.5 and 4.3%, respectively. However, when two predictive factors were present, the HI risk and the postoperative morbidity were 53.8 and 30.8%, respectively. Perioperative HI, defined as the need for a cumulative dose of norepinephrine >5mg, is significantly associated with postoperative morbidity and can be predicted by symptomatic preoperative high blood pressure and above a ten-fold increase in urinary metanephrine and/or normetanephrine levels.

Clinical predictors of prolonged postresection hypotension after laparoscopic adrenalectomy for pheochromocytoma

Although the perioperative management of patients with pheochromocytoma has been improving recently, severe hypotensive episodes can occur that require postoperative catecholamine support and are challenging to manage. Our aim was to identify the clinical factors that predict prolonged postresection hypotension in patients after laparoscopic adrenalectomy for pheochromocytoma. The records of 73 Japanese patients who underwent unilateral laparoscopic adrenalectomy for pheochromocytoma were surveyed retrospectively. Patients were divided into 2 groups according to whether catecholamine support was needed after postoperatively. Clinical and biochemical data were evaluated at baseline and after operation. Thirty-four of 73 patients (47%) required continuous infusion of catecholamine to maintain systolic blood pressure >90 mm Hg at the end of the operation. The median duration of postoperative catecholamine support was 17 hours (range, 3-130) in these 34 patients. On multivariate analysis, tumor size >60 mm, urinary epinephrine levels >200 μg/day, and urinary norepinephrine levels >600 μg/day were independent predictors of prolonged hypotension requiring postoperative catecholamine support. Tumor size and urinary norepinephrine levels were significantly correlated with the duration of postoperative catecholamine support. Larger tumor size and greater values of urinary epinephrine and norepinephrine levels were significant predictors of prolonged hypotension requiring postoperative catecholamine support. Moreover, tumor size and urinary norepinephrine levels were positively correlated with the duration of postoperative catecholamine support. Clinicians can identify and manage patients more effectively with a greater risk of prolonged hypotension after tumor resection using these preoperative clinical variables.