From Lewis Blevins, MD – Bilateral adrenalectomy has always been an option to treat hypercortisolism due to Cushing’s disease due to an ACTH-secreting pituitary tumors. It is not considered first line treatment as it is always best to attempt to resolve the hypercortisolism by treating the pituitary tumor and so remedying the hypercortisolism. Further, the complication rates of major abdominal or flank surgery in patients with cortisol excess are high and can be fatal. Wound infections, bleeding, impaired wound healing, blood clots, and adrenal crisis are just a few of the life-threatening issues that result in bilateral adrenalectomy being a treatment of last resort.
In fact, bilateral adrenalectomy is often reserved for those with residual or recurrent Cushing’s disease who are quite ill with marked hypercortisolism that fails to respond to medical therapy. Many of these patients are not candidates for additional pituitary surgery. Most have been treated with multiple drugs and had either failed to respond or had partial responses to treatment. Even though radiotherapy to the pituitary tumor might be an option, the morbidities of hypercortisolism are so severe that they may claim the patients life. Bilateral adrenalectomy is the easy and only out of the state of severe hypercortisolism for some of these patients.
Patients with ectopic ACTH hypersecretion and tumors that are metastatic or incompletely resected often require bilateral adrenalectomy in the same clinical settings as those with pituitary tumors.
Adrenal adenoma and unilateral hyperplasia patients typically require a unilateral adrenalectomy. They can also try medications in lieu of surgery if they are not surgical candidates or prefer to avoid surgery and anesthesia.
Patients with bilateral adrenal hyperplasia and hypercortisolism often undergo bilateral adrenalectomy when they fail or are intolerant of medical therapy. Some prefer this form of treatment and feel that glucocorticoid and mineralocorticoid replacement are superior to adrenal biosynthesis inhibitors. I don’t disagree with the notion that this trade off, adrenal insufficiency for hypercortisolism, is reasonable. Both have significant risks. Adrenal insufficiency is easier to manage.
Some centers believe that bilateral adrenalectomy with the laparoscopic and robotic techniques are simple, less invasive, and safe enough to recommend surgery sooner rather than later. They believe in operating before patients develop complicated hypercortisolism. This makes sense. I will say that it’s a matter to be decided after extensive discussions between doctors and patients and their families.
The laparoscopic approach has revolutionized adrenal surgery compared to the old ways of doing the procedure through the abdomen or the flanks. Most patients now spend one to two days in the hospital relative to the 10 to 14 days that used to be required to recover. The new approaches are infinitely less painful. I was reminded of this recently when a patient I care for required conversion from laparoscopic to an open procedure for removal of her right adrenal gland. She had a previous left adrenalectomy for what proved to be PPNAD. She remained hypercortisolemic and we elected to remove the right gland, too. She had had a rough time recovering that is in keeping with my experiences of yesteryear before the advent of the laparoscopic approach.
Some centers advocate for nodule removal or partial adrenalectomy in patients with isolated adenomas or hyperplasia. I don’t advocate for these approaches given my knowledge of the blood supply to the adrenals, the venous drainage, risks of adrenal hemorrhage, that adrenals are prone to autolysis and necrosis, and the potential for a catecholamine storm. Further, for those with hyperplasia, partial removal may prove to be a temporizing measure and additional surgery may be required at a later time after the remaining tissue becomes more hyperplastic. It will be of interest to follow the research in this arena.
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