Surgical management of primary aldosteronism

Laparoscopic transabdominal lateral adrenalectomy

Laparoscopic adrenalectomy is a mainstay of operative options for adrenal tumors and allows surgeons to perform adrenalectomies with less morbidity, less post-operative pain, and shorter hospital stays. The literature has demonstrated its efficacy to be equal to open adrenalectomy in most cases. With regard to malignant primary and metastatic lesions, controversy still remains, however, consideration of a laparoscopic approach for smaller, well circumscribed and non-invasive lesions is reasonable. During any laparoscopic resection, when there is doubt about the ability to safely remove the lesion with an intact capsule, conversion to an open approach should be considered. The primary goal of a safe and complete oncologic resection cannot be compromised. For most benign lesions, laparoscopic approaches are safe and feasible and conversion to an open approach is necessary only for lesions where size limits the ability of a minimally invasive resection.

Laparoscopic adrenalectomy: Gaining experience by graded approach

INTRODUCTION

Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success.

MATERIALS AND METHODS

The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used.

RESULTS

The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min) and 190 min (150-310 min) in Group B. Average blood loss was 136.93 cc (20-400 cc) in Group A and 92.5 cc (40-260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days) in Group A and 2.6 days (2-4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4-61 months).

CONCLUSION

LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.

The current status of laparoscopic adrenalectomy

In this article the authors have attempted to summarize and evaluate the current literature regarding the feasibility and indications of the laparoscopic approach to the resection of adrenal lesions. The overall results suggest that laparoscopic adrenalectomy is safe, effective, and has major advantages for patients in terms of decreased pain, hospital stay, and short- and long-term morbidity. For large and malignant lesions, good judgment and careful consideration must be given to the entire clinical picture so that the laparoscopic approach is used for patients who will derive benefits from the minimally invasive approach without compromising an oncologically sound resection or safety of operation. Additional studies will help clarify these remaining controversies further. The laparoscopic approach for adrenalectomy has demonstrated that significant and beneficial advances in surgery are improving the care offered patients.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice for small benign lesions. Compared with open adrenalectomy (OA), it appears to achieve superior results in terms of recovery, cosmesis and morbidity.

METHODS

A Medline literature search (PubMed database, 1990-2003) was undertaken to identify relevant English language papers. Studies comparing LA with OA were categorized according to their level of evidence. Variables of outcome were analysed systematically for various adrenal pathologies.

RESULTS

No prospective randomized studies comparing LA with OA were identified. According to 20 comparative case-control studies (level 3b) and many case-series reports (level 4), the results of LA were reproducible and it has consistently been associated with faster recovery and lower morbidity than OA. The clinical outcome in hormonally active lesions was similar. The lateral transabdominal approach was the laparoscopic technique of choice; it was practised by 78.6 per cent of surgeons. Lesion sizes of 10-12 cm were cited as the upper limit for LA in many large series. Experience of 70 malignancies demonstrated the feasibility of LA, with short-term oncological results comparable to those of conventional surgery.

CONCLUSION

Despite a lack of a high level of evidence in its favour, LA has practically replaced OA in the management of small and medium-size benign functioning and non-functioning adrenal lesions, as it has proved to be as effective as OA with less associated morbidity. Although limited experience with large and malignant tumours shows some promise, present data are insufficient for clear conclusions to be drawn.

Clinical manifestation of aldosteronoma

Formerly, fewer than 1% of patients with hypertension were believed to have primary hyperaldosteronism; however, recent studies have suggested a higher prevalence, in 5% to 10% of patients with hypertension. Hypokalemia is not necessary for the diagnosis and is probably a sign of more advanced disease. The best diagnostic test is the plasma aldosterone concentration to plasma renin activity (PAC/PRA) ratio. Excess aldosterone level has a deleterious effect on the cardiovascular system. Aldosteronomas should be differentiated from idiopathic hyperaldosteronism (IHA),because they are curable by laparoscopic adrenalectomy.