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Paduraru DN, Nica A, Carsote M, Valea A. Adrenalectomy for Cushing's syndrome: do's and don'ts. J Med Life 2016; 9:334-341. [PMID: 27928434 PMCID: PMC5141390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aim. To present specific aspects of adrenalectomy for Cushing’s syndrome (CS) by introducing well established aspects (“do’s”) and less known aspects (“don’ts”). Material and Method. This is a narrative review. Results. The “do’s” for laparoscopic adrenalectomy (LA) are the following: it represents the “gold standard” for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients’ selection and the surgeon’s skills. The “don’ts” are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The “don’ts” are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the “do’s” are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing’s disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing’s syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA. Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women. Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing’s disease, CS = Cushing’s syndrome, ECS = Ectopic Cushing’s syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing’ syndrome
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Affiliation(s)
- D N Paduraru
- Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Department of Surgery, University Emergency Hospital, Bucharest, Romania
| | - A Nica
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesiology, University Emergency Hospital, Bucharest, Romania
| | - M Carsote
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; Department of Endocrinology, "C. I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - A Valea
- "I. Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Endocrinology, Clinical County Hospital, Cluj-Napoca, Romania
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Tanaka M, Ikeda Y, Matsui S, Kato A, Nitori N, Kadomura T, Hatori T, Kitajima M. Right lateral decubitus approach to a laparoscopic modified Hassab's operation. Asian J Endosc Surg 2016; 9:97-100. [PMID: 26781539 DOI: 10.1111/ases.12252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 10/05/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The lateral approach is the standard for laparoscopic splenectomy. However, when the modified Hassab's operation is performed laparoscopically, the patient is placed in the supine position and then the right semi-lateral or lateral decubitus position. Based on our experience with laparoscopic adrenalectomy and splenectomy, we laparoscopically performed the modified Hassab's operation with the patient in the right lateral decubitus position. MATERIALS AND SURGICAL TECHNIQUE Indications for the modified Hassab's operation for patients with portal hypertension in our institute include both gastric varices and hypersplenism resistant to endoscopic or radiologic procedures. We performed splenectomy and devascularization of the greater curvature and then dissected adhesions between the stomach, pancreas, and gastrohepatic ligament. With the patient in the right lateral decubitus position, the lesser curvature could be identified from both the ventral and dorsal sides. DISCUSSION For the modified Hassab's operation, as in laparoscopic gastrectomy, many operators select the supine position for lesser curvature devascularization and gastric vessel ligation. However, after sufficient adhesion dissection around the stomach, anatomical structures can be identified in the right lateral decubitus position. For this approach, gravity is not an issue on the dorsal side, and the lesser curvature can be observed from both the ventral and dorsal sides with the patient in the right lateral decubitus position. Laparoscopically performing the modified Hassab's operation with the patient in the right lateral decubitus position is a feasible method.
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Affiliation(s)
- Motomu Tanaka
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Yoshifumi Ikeda
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Shimpei Matsui
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Ayu Kato
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Nobuhiro Nitori
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Tomohisa Kadomura
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Takashi Hatori
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Masaki Kitajima
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
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Ho CH, Liao PW, Lin VC, Jaw FS, Chueh SCJ, Chung SD, Liu SP, Tsai YC, Yu HJ. Laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-access platform and standard laparoscopic instruments: technical considerations and surgical outcomes. Asian J Surg 2014; 38:6-12. [PMID: 24661450 DOI: 10.1016/j.asjsur.2014.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/29/2013] [Accepted: 01/14/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND We previously reported our initial experience with laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-port device and conventional straight laparoscopic instruments. METHODS Between December 2010 and February 2012, LESS retroperitoneal partial adrenalectomies were performed in 11 patients. Six patients had aldosterone-producing adenomas (APAs) and five patients had nonfunctioning tumors. A single-port access was created with an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) through an incision of 2-3 cm beneath the tip of the 12th rib. All procedures were performed with straight laparoscopic instruments. RESULTS All LESS procedures were successfully completed without conversion to traditional laparoscopic conversion. The tumors ranged from 1 cm to 4.7 cm (mean, 2.3 cm). The operative time was 71-257 minutes (mean, 121 minutes). Most patients (n = 8) had minimal blood loss; the other three patients had a blood loss of 150 mL, 100 mL, and 100 mL. The mean hospital stay was 3 days (range, 1-6 days). There were no perioperative or postoperative complications. Pathological examinations revealed negative surgical margins in all specimens. All patients with Conn's syndrome had an improvement in blood pressure and normalization of plasma renin activity and serum aldosterone levels; all patients were free of potassium supplementation. CONCLUSION Our results clearly demonstrate that LESS retroperitoneal partial adrenalectomy can be performed safely and effectively using a custom-made single-access platform and standard laparoscopic instruments.
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Affiliation(s)
- Chen-Hsun Ho
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Pin-Wen Liao
- Department of Neurology, Cathay General Hospital, Taipei, Taiwan; Department of Medicine, School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Victor C Lin
- Department of Urology, E-Da Hospital, Kaohsiung, Taiwan; Department of Healthcare Administration, I-Shou University, Kaohsiung, Taiwan
| | - Fu-Shan Jaw
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Shih-Chieh Jeff Chueh
- Glickman Urological and Kidney Institute and Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Shiu-Dong Chung
- Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Ban Ciao, Taipei, Taiwan
| | - Shih-Ping Liu
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Chou Tsai
- Division of Urology, Department of Surgery, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan; Department of Urology, College of Medicine, Tzu Chi University, Hualien, Taiwan.
| | - Hong-Jeng Yu
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
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Kaye DR, Storey BB, Pacak K, Pinto PA, Linehan WM, Bratslavsky G. Partial adrenalectomy: underused first line therapy for small adrenal tumors. J Urol 2010; 184:18-25. [PMID: 20546805 PMCID: PMC3164765 DOI: 10.1016/j.juro.2010.03.052] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Indexed: 12/14/2022]
Abstract
PURPOSE Many patients with small adrenal masses undergo total adrenalectomy. We evaluated partial adrenalectomy outcomes by performing a comprehensive literature review. MATERIALS AND METHODS We performed a PubMed search of the English language literature using the queries partial adrenalectomy and adrenal sparing surgery, and identified 317 and 155 articles, respectively. We excluded case reports or series with fewer than 5 patients, articles not focused on surgical management and those that did not indicate perioperative outcomes. The remaining articles were cross-referenced by author and institution to eliminate studies with redundant cases. Demographics, diagnosis, tumor characteristics, perioperative and functional outcomes, and recurrence data were collected when available. RESULTS A total of 22 articles from a total of 22 first authors met our inclusion criteria, describing outcomes in a total of 417 patients. There has been an increasing trend toward partial adrenalectomy worldwide in the last 20 years. Partial adrenalectomy is most commonly done for Conn's syndrome, followed by pheochromocytoma. Most procedures are laparoscopic with minimal morbidity. The recurrence rate is only 3% and more than 90% of patients remain steroid independent. CONCLUSIONS Partial adrenalectomy surgical outcomes and perioperative complications are similar to those reported for total adrenalectomy. When partial adrenalectomy is done for small adrenal lesions, the malignancy rate is negligible, the recurrence rate is low and most patients remain steroid-free at long-term followup. These data strongly support the acceptance of partial adrenalectomy as first line treatment for small adrenal masses.
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Affiliation(s)
| | | | | | | | | | - Gennady Bratslavsky
- Correspondence: Gennady Bratslavsky, M.D. Urologic Oncology Branch National Cancer Institute Building 10 Room 1-5940 Bethesda, Maryland 20892-1107 Tel: 301 496-6353 Fax: 301 402-0922
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Wang XJ, Shen ZJ, Zhu Y, Zhang RM, Shun FK, Shao Y, Rui WB, He W. Retroperitoneoscopic partial adrenalectomy for small adrenal tumours (≤1 cm): the Ruijin clinical experience in 88 patients. BJU Int 2010; 105:849-53. [DOI: 10.1111/j.1464-410x.2009.08878.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
The concept of organ- and function-preserving surgery without compromising the primary goal of complete tumour removal has been recently applied in adrenal surgery. This has been accomplished by open surgery in the past. With recent advancements in minimally invasive surgery, partial adrenalectomy by laparoscopic approach has become feasible. The indications, contraindications and worldwide experience have been reviewed for this article.
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Affiliation(s)
- T Nambirajan
- Department of Urology, Elisabethinen Hospital, Linz, Austria.
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Erbil Y, Salmaslioğlu A, Barbaros U, Bozbora A, Mete O, Aral F, Ozarmağan S. Clinical and radiological features of adrenal cysts. Urol Int 2008; 80:31-6. [PMID: 18204230 DOI: 10.1159/000111726] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 11/16/2006] [Indexed: 11/19/2022]
Abstract
Adrenal cysts are very rare lesions, usually asymptomatic or without characteristic symptoms. They are classified as pseudocysts, endothelial cysts, epithelial cysts or parasitic cysts. Although pseudocysts are reported to be the most common clinically recognized adrenal cysts in surgical series, endothelial cysts are more common in autopsy series. We studied 15 consecutive patients with adrenal cysts who underwent surgical resection at our institution from 1990 to 2005. Of 15 patients with adrenal cysts, 10 had pseudocysts, 3 epithelial cysts, 1 an endothelial cyst and 1 a parasitic cyst. In conclusion, a better understanding of cystic adrenal masses is necessary to recognize true adrenal cysts and differentiating them from adrenal carcinoma or adenoma by demonstrating the foci of cystic or degenerative changes.
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Affiliation(s)
- Yeşim Erbil
- Department of General Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
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Abstract
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.
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Affiliation(s)
- Andrew A Gumbs
- New York-Presbyterian Hospital, Division of Laparoscopic and Bariatric Surgery and Department of Surgery, Joan and Sanford I. Weill Medical College of Cornell University, PO Box 294, New York, NY 10021, USA
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Mathonnet M. [Management of adrenal incidentaloma combined with high blood pressure]. ACTA ACUST UNITED AC 2005; 130:303-8. [PMID: 15935786 DOI: 10.1016/j.anchir.2005.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2004] [Accepted: 03/16/2005] [Indexed: 10/25/2022]
Abstract
Hypertension (HTA) is a very common disease but its origin is well known only in 1 to 5% of the cases. HTA is present in half of the patients who have an adrenal incidentaloma. Clinical data, hormonal sampling, computed tomography and adrenal scintigraphies are necessary to identify hyperfunctioning adrenal tumors. Adrenalectomy is indicated in case of potential malignant tumors and hyperfunctioning tumors. If HTA seems to be not in relation with the adrenal mass, it is recommended to recognize a congenital enzymatic block in order to ovoid an unnecessary adrenalectomy and to search for a preclinical Cushing's syndrome. The last one is associated with HTA in 91% of the cases, and with a morbid obesity, mellitus diabetes or dyslipidemia in 50% of the cases. The removal of the adrenal mass improves the HTA for half of the patients. If the adrenocortical tumor is nonfunctioning, patients have to be followed during a long time. HTA will be considered as "essential" after a new comprehensive analysis performed 3 years later.
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Affiliation(s)
- M Mathonnet
- Service de chirurgie digestive et endocrinienne, CHU de Dupuytren, 87042 Limoges, France.
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Nambirajan T, Leeb K, Neumann HPH, Graubner UB, Janetschek G. Laparoscopic Adrenal Surgery for Recurrent Tumours in Patients with Hereditary Phaeochromocytoma. Eur Urol 2005; 47:622-6. [PMID: 15826753 DOI: 10.1016/j.eururo.2005.01.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Accepted: 01/07/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To report our experience with Laparoscopic Partial Adrenalectomy (LPA) for recurrent tumours in patients with hereditary phaeochromocytoma. PATIENTS AND METHODS Five patients with hereditary phaeochromocytoma (4 with von Hippel-Lindau disease and 1 with Multiple Endocrine Neoplasia 2B), who had undergone adrenal surgery previously, presented with recurrent adrenal tumours. One patient was pregnant at 20 weeks of gestation. All patients underwent hormonal evaluation, genetic screening and imaging with CT or MRI, metaiodobenzylguanidine (MIBG) scintigraphy. RESULTS Of the 7 attempted LPA in five patients, five procedures (71%) were successfully completed and total adrenalectomy was needed on two occasions. The adrenal vein could be spared in all patients except one. There were no intra-operative complications. The adrenal function was adequate in all patients without need for steroid supplementation except one patient who lost both adrenals eventually. There was no correlation between the preservation of adrenal vein and adrenocortical function. CONCLUSION Laparoscopic partial adrenalectomy is feasible, safe and effective in recurrent phaeochromocytoma, despite previous adrenal surgery and is technically easier if the previous approach had been laparoscopic as well. Patients with hereditary phaeochromocytoma are prone for recurrent tumours and may need repeated surgical procedures. Hence, minimally invasive approach is ideal for these patients.
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Mirallié E, Cariou B, Kraeber-Bodéré F. Phéochromocytomes bilatéraux. Génétique et traitement. ACTA ACUST UNITED AC 2005; 130:273-6. [PMID: 15847867 DOI: 10.1016/j.anchir.2005.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- E Mirallié
- Clinique chirurgicale A, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 01, France.
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Micali S, Peluso G, De Stefani S, Celia A, Sighinolfi MC, Grande M, Bianchi G. Laparoscopic Adrenal Surgery: New Frontiers. J Endourol 2005; 19:272-8. [PMID: 15865511 DOI: 10.1089/end.2005.19.272] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
After about 10 years of experience, laparoscopic adrenalectomy has become the gold standard for the treatment of adrenal lesions. Here, we describe the presenting features, imaging methods, and current surgical approaches to diseases of the adrenal gland. There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions, but controversy exists about using laparoscopy for suspected adrenal malignancy, metastasis, and partial adrenalectomy. This article reviews the literature on laparoscopic adrenalectomy. In particular, we focus our attention on the new surgical approaches to the gland. We evaluate the indications, operative techniques, and tools for partial adrenalectomy, and we discuss new surgical strategies such as cryosurgery and radiofrequency ablation.
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Affiliation(s)
- Salvatore Micali
- Department of Urology, University of Modena, Via del Pozzo 71, 41100 Modena, Italy.
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Abstract
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.
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Affiliation(s)
- A Assalia
- Division of Laparoscopy and Department of Surgery, Weill-Cornell College of Medicine, New York-Presbyterian Hospital, New York, New York 10021, USA
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Walz MK. Extent of adrenalectomy for adrenal neoplasm: cortical sparing (subtotal) versus total adrenalectomy. Surg Clin North Am 2004; 84:743-53. [PMID: 15145232 DOI: 10.1016/j.suc.2004.01.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The standard operation on adrenal neoplasias is a complete adrenalectomy. Accepted exceptions are bilateral inherited pheochromocytomas. In these cases, clinical and biochemical cure, as well as preservation of cortical function, can be achieved by a noncomplete adrenalectomy. In that procedure, at least one third of one gland has to be preserved. In unilateral adrenal tumors, partial resection has been used, especially in Conns adenomas, with early results comparable to those of total adrenalectomy. Because longterm results are still limited in hyperaldosteronism, final conclusions are not possible today.
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Affiliation(s)
- Martin K Walz
- Clinic of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Duisburg-Essen, Henricistrasse 92, D-45136, Essen, Germany.
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Abstract
PURPOSE Pheochromocytomas and paragangliomas are rare tumors of chromaffin cell origin. Their identification is likely increasing owing to the increased use of radiographic images detecting incidental adrenal masses. RECENT FINDINGS The pathophysiology of hypertension induced by the release of catecholamines and newly discovered peptides has been shown to be more complex than the concept of episodic catecholamine release. SUMMARY This review looks at the most recent advances in the physiology and molecular basis of these tumors.
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Affiliation(s)
- Sanziana Roman
- Yale University School of Medicine, New Haven, CT 06520, USA.
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